Failure to Maintain Low Air Loss Mattress in Safe Working Condition
Summary
The facility failed to ensure that a low air loss mattress was maintained in proper working order for a resident with multiple pressure ulcers and complex medical conditions. The resident, who was cognitively intact and required substantial assistance for mobility, had a care plan that included the use of a low air loss bariatric mattress for pressure reduction due to her high risk for skin breakdown and existing stage 3 pressure ulcers. Despite this, the mattress provided to her was not functioning correctly, as the hose that kept the mattress inflated repeatedly disconnected, causing the mattress to deflate and leaving the resident lying on a hard metal bed frame. Multiple staff members, including a CNA and an LPN, confirmed that the mattress was not staying inflated and that the hose would frequently come off, sometimes requiring makeshift repairs such as duct tape to keep it in place. Family members also reported the issue to facility leadership, providing photographic evidence and written communication about the malfunctioning equipment. The resident herself described experiencing extreme pain, rating it as a 10 out of 10, particularly when the mattress lost air and she was left without adequate pressure relief for her wounds. Interviews with the wound care nurse practitioner and review of the resident's care plan confirmed that the use of a properly functioning low air loss mattress was a necessary intervention for her condition. The facility's own preventive maintenance policy required systematic inspection and timely repair or replacement of essential equipment, but the failure to maintain the mattress in working order resulted in the resident enduring significant pain and inadequate pressure relief for an extended period.
Penalty
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Surveyors found that the facility did not maintain a documented maintenance schedule for its two AC units and relied only on undocumented daily visual checks by maintenance staff. One AC unit was not working while a belt was being changed, and another had been nonfunctional previously. An AC technician reported that the units required monthly PM, including filter changes and testing of water valves and pneumatic controls, but these tasks were not part of the facility’s PM program. Review of the facility’s maintenance policy showed that the Maintenance Director was required to develop and maintain maintenance schedules for building systems, which was not done, creating the potential for residents in general to lack a comfortable environment.
Frayed and exposed wires were observed on bed remote controls in the rooms of three residents, including residents with impaired cognition, mobility dependence, and diagnoses such as paraplegia, muscle weakness, and depression. Staff stated the exposed wiring should not have been present because of the risk of electrocution, and one bed remote was also not working when used for care. In a separate room, a resident’s call light did not activate the light outside the door or ring at the nurse’s station, and the resident reported being unable to get help when calling for assistance.
Walk-In Freezer Not Maintained: The facility failed to keep the walk-in freezer free of water drippings and ice build-up. During kitchen observation, the freezer ceiling had numerous frozen water drops and the floor had three frozen areas about 12 inches in diameter. The CD said the condition had been present for a couple of weeks and that the frozen water on the floor was a safety hazard. The CD could not find a work order, and the DM said he was not aware of the current build-up.
Surveyors found that the crash cart contained multiple expired or out-of-date emergency supplies, including a suction machine overdue for inspection, expired iodine packets, aspirin, a biohazard spill kit, airway tubes, suction components, small bore extension kits, a central line dressing kit, and a heat pack. The DON confirmed the items were expired but reported believing the dates were manufacturing dates and stated that monthly checks of the crash cart were performed using a checklist that did not record expiration dates. Review of facility documentation showed completed checklists with all items marked as present but no tracking of expirations, and an office manager confirmed there was no active crash cart policy in place, despite an undated written policy stating that crash carts would be kept in a constant state of readiness and that expiration dates would be routinely monitored.
Crash cart checks on the Main Nursing Unit were not consistently documented, with missing RN Supervisor signatures on multiple dates. An observation found an opened, expired Ambu bag and an opened Suction Cath-N-Glove kit on the cart, and an RN confirmed the missing signatures and expired/open supplies.
The facility failed to ensure shower chairs functioned safely, as multiple plastic-framed chairs with plastic casters could slide and roll on tile floors even when wheel brakes were fully engaged. A cognitively intact resident who required partial to moderate assistance for transfers fell when a shower chair moved backward and a wheel came out during a transfer to a wheelchair, despite staff reporting that the brakes were locked. CNAs, an LPN, the DON, and maintenance staff observed and demonstrated that several shower chairs could be easily moved or rolled with brakes applied, and one bariatric chair had locks on only two rear wheels, allowing the front to swing side to side. Staff reported they did not rely on the brakes and instead physically held the chairs during use, and the facility could not provide manufacturer instructions for the shower chairs.
Failure to Maintain AC Preventative Maintenance Schedule and Critical Component Testing
Penalty
Summary
The facility failed to maintain a documented maintenance schedule for its two air conditioning (AC) units and did not include testing of water valves and pneumatic controls in its preventative maintenance program. During interviews, the Maintenance Supervisor (MS) reported that the facility had two AC units, with the front unit currently working and the back unit not working due to a belt change. The MS stated that the front unit had not been working approximately two months earlier. The MS explained that the only preventative maintenance performed on the AC units was a daily visual inspection, and that the facility did not keep any log or documentation of these daily checks. In a telephone interview, the AC technician stated that they had been called to the facility a few weeks earlier for AC issues and indicated that the facility’s AC units required monthly preventative maintenance, including changing filters, testing water valves, and testing pneumatic controls. The MS reported that the AC technician had previously informed them that the problem with the AC unit was related to water valves on the roof that needed to be exercised (opened and closed). Review of the facility’s Maintenance Service policy, revised December 2009, showed that the Maintenance Department was responsible for maintaining buildings, grounds, and equipment in a safe and operable manner, providing routinely scheduled maintenance service, and that the Maintenance Director was responsible for developing and maintaining a schedule of maintenance service and maintaining maintenance schedules. The failure to maintain such schedules and to include testing of water valves and pneumatic controls in preventative maintenance had the potential for residents in general not to have a comfortable environment while at the facility.
Frayed bed remotes and nonfunctioning call light
Penalty
Summary
The facility failed to maintain resident care equipment in safe operating condition when bed remote controls for three residents were observed with frayed and exposed wires near the control pad. Resident 49 was admitted with diagnoses including difficulty walking, muscle weakness, and spondylopathy of the lumbosacral region. The resident’s record showed the resident had the capacity to understand and make decisions at admission, while the MDS later indicated severe cognitive impairment and dependence for mobility and ADLs. During observation in the resident’s room, the bed remote control had peeling wires that were frayed and exposed, and the RNA stated the remote should have no exposed wires to prevent electrocution. Resident 136 was admitted with diagnoses including major depressive disorder, generalized anxiety disorder, and restlessness and agitation. The resident’s H&P indicated the resident did not have the capacity to understand and make decisions, and the MDS showed severe cognitive impairment, dependence for mobility and ADLs, and high fall risk. During observation in the resident’s room, the bed remote had peeling and exposed wires near the control pad. The CNA stated there should be no exposed electrical wires in the resident’s environment because of the risk of accidents such as electrocution. Resident 3 was admitted and later readmitted with diagnoses including a stage four sacral pressure ulcer, paraplegia, and major depressive disorder. The resident’s H&P indicated the resident did not have the capacity to understand and make decisions, and the MDS showed moderately impaired cognition and dependence for mobility and ADLs. During observation in the resident’s room, the bed remote control had frayed and exposed wires near the control pad, and the CNA stated there should be no exposed electrical wires to prevent accidents such as electrocution. The CNA also attempted to use the bed remote to elevate the bed for care, but the remote was not working. The facility also failed to maintain the resident call system in functional condition for Resident 41, who was admitted with diagnoses including hemiplegia and hemiparesis following cerebral infarction, essential hypertension, and morbid obesity. The MDS showed the resident could make self-understood and understand others, had moderate cognitive impairment, and needed maximal assistance with mobility and ADLs. The resident stated the resident had been calling to be changed but no one would go to the room. When the resident pressed the call light, the light outside the room did not illuminate or ring at the nurse’s station. CNA 7 and ADON 2 observed the same malfunction, and CNA 7 stated the resident would not be able to call for assistance if the call light was not working.
Walk-In Freezer Not Maintained
Penalty
Summary
The facility failed to ensure the walk-in freezer was maintained so that water drippings and ice build-up would not affect frozen food storage. During an observation of the kitchen, the walk-in freezer ceiling had numerous frozen water drops extending into the middle of the freezer across from the two fans on the left side, and the floor had three frozen areas approximately 12 inches in diameter. The culinary director stated the freezer had been in that condition for a couple of weeks and that the regional person had come out and de iced it, and also stated the frozen water on the floor was a safety hazard. The culinary director was unable to find a work order for the de icing. The director of maintenance stated there had been a work order for ice build-up on the freezer and that he had defrosted it and replaced a door gasket on a prior occasion, but he was not aware of the current build-up. He also stated any staff could place a work order or notify a manager. A policy for maintaining equipment was requested but was not received.
Failure to Maintain Crash Cart Medications and Equipment in Safe Operating Condition
Penalty
Summary
The facility failed to maintain emergency medications and equipment on the crash cart in safe operating condition. During observation of the crash cart, surveyors identified multiple expired or out-of-date items, including a suction machine with an inspection sticker indicating the next inspection was due several months earlier, five packets of iodine, a bottle of aspirin, a biohazard spill kit, 11 airway tubes, a suction tip, suction tubing, small bore extension kits, a central line dressing kit, and a heat pack, all with past or outdated expiration or use-by dates. The DON, present during the observation, confirmed that the suction machine was past due for inspection and acknowledged the expired supplies, but stated she believed the dates were manufacturing dates rather than expiration dates. The DON reported that the facility conducted monthly checks of the crash cart contents and maintained a binder with a checklist of required equipment. Review of this crash cart binder showed three checklists with all items marked as present, but no expiration dates were documented for any supplies. When a crash cart policy was requested, the office manager confirmed that the facility had no policy regarding the crash cart, its audits, or its maintenance. An undated facility policy titled "Crash Cart Audit Policy and Procedure" stated that crash carts would be maintained in a state of readiness, that missing, expired, or damaged items would be replaced promptly, and that a trained staff member would maintain and routinely monitor a running inventory of expiration dates, but the observations and interviews showed this was not being implemented.
Crash Cart Not Maintained in Safe Operating Condition
Penalty
Summary
The facility failed to keep the Main Nursing Unit crash cart in safe operating condition. Facility documentation stated the emergency cart was to be checked daily by the night shift RN Supervisor for expiration dates and missing items, but the records reviewed showed missing signatures on multiple dates in January and February 2026. During an observation of the crash cart at the Main Nurses Station, the surveyor found an opened Ambu bag that had expired and an opened Suction Cath-N-Glove kit. During an interview, RN Employee E3 confirmed the missing signatures and the expired/open supplies on the crash cart.
Unsafe Shower Chairs with Ineffective Brakes Used During Resident Transfers
Penalty
Summary
The facility failed to maintain safe shower chair equipment, resulting in unstable and malfunctioning shower chairs being used for resident care. One resident with intact cognition who required partial to moderate assistance for tub/shower and sit-to-stand transfers reported that during a transfer from a shower chair to her wheelchair, the shower chair moved backward and she fell, despite having asked the CNA to confirm that both the shower chair and wheelchair were locked. The facility’s incident note documented that during this transfer, one of the wheels from the shower chair came out, causing the resident to lose balance and fall to the floor. The DON stated that the resident reported pulling up on her wheelchair during the transfer and that the shower chair “popped out” even though the wheels were locked, and examination of the involved shower chair showed a plastic frame with plastic casters, only two of which had locks. Further observations and staff interviews showed that multiple shower chairs in the facility did not remain stationary even when all wheel locks were applied. The DON and other staff demonstrated that when sitting in or pushing the plastic shower chairs with the brakes locked, the chairs could still be propelled backward or rolled on the tile floor, and the locked wheels slid easily and then rolled despite the brakes being engaged. A CNA and an LPN reported that some shower chairs moved and slid on the tile even if all four wheels were locked, and that staff had to physically hold the chairs during resident use because the plastic wheels allowed the chairs to slide and roll even with brakes applied. The Maintenance Director initially stated he had no concerns about the brakes and believed CNAs knew they had to hold the chairs because they slid on tile regardless of the locks, but later acknowledged that on reexamination of the involved chair, the wheels did turn despite the brake mechanism being applied. Additional observations showed that residents were being transferred and transported in shower chairs whose brakes did not effectively prevent movement. In one instance, a CNA, while holding a resident’s incontinence brief, used one arm to easily move a shower chair away from the resident’s back even though she stated all brakes were engaged, and she demonstrated that the wheels rolled with the brakes locked, noting that most of the chairs were like that and that she did not rely on the brakes. In another instance, a CNA locked the wheels of a plastic-wheeled shower chair in a resident’s room, yet the resident was able to slide the chair back and forth by holding the armrest during transfer, and the chair slid backward when the resident sat down; the resident was then transported down the hall in the same chair with the brakes still locked. The DON and a corporate consultant also observed multiple plastic shower chairs, including a bariatric chair with only two rear wheel locks, whose wheels moved and rolled on the floor despite the brakes being locked. The facility was unable to provide a manufacturer’s instruction manual for the shower chairs in use.
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