Improper Weight-Based Settings of Low Air Loss Mattresses
Summary
The deficiency involves the facility’s failure to maintain proper use and settings of low air loss (LAL) mattresses for four of six residents reviewed, despite physician orders and facility policy requiring licensed nurses to monitor function, proper setup, and placement. LAL mattresses in the subacute unit were equipped with pumps whose air pressure is set according to resident weight, with yellow arrows placed on each pump by the Subacute Unit Coordinator (SAC) to indicate the correct setting. The facility’s policy on low-air-loss therapy beds states that these beds inflate to specific pressures based on the height and weight of the patient. Surveyors observed multiple instances where the LAL pump settings did not match the indicated weight-based settings. For one resident weighing 117 lbs, the yellow arrow on the pump was placed between 80 and 160 lbs, but the dial was set at 400 lbs until RN 1 adjusted it to align with the arrow. For a second resident weighing 144 lbs, the yellow arrow was between 100 and 150 lbs, but the dial was set at 350 lbs on the “Firm” setting, which the SAC confirmed was incorrect. For a third resident weighing 150 lbs, the yellow arrow was between 80 and 160 lbs, but the dial was set at 400 lbs on the “Max” setting, which the SAC also verified was not correct. For a fourth resident weighing 183 lbs, the yellow arrow was at 200 lbs, but the pump was set at 285 lbs, which LVN 1 acknowledged was incorrect and resulted in an overinflated, hard surface. Interviews confirmed that staff were aware of the requirement to set LAL pumps according to resident weight and to verify settings. RN 1 and the SAC explained that the yellow arrows were placed to guide staff to the correct setting based on weight, and that proper settings help relieve pressure on the skin and minimize the risk of pressure ulcer development. The SAC stated it was her expectation that the assigned LVN check and verify LAL pump settings at the beginning of each shift. LVN 1 stated he checks his residents’ LAL pumps at the beginning and end of his shift and after resident care, and verified he was assigned to one of the residents with an incorrect setting; he reported that he had checked the pump earlier and believed it was correct, and acknowledged he did not re-check the setting after providing wound treatment. LVN 1 also stated he did not think he checked the fourth resident’s mattress setting that day and acknowledged he should have. All four residents had severe cognitive impairment and physician orders for LAL mattresses with licensed nurses to monitor function, proper setup, and placement.
Penalty
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Expired supplies were found in two crash carts on nursing units 1B and 2B. An opened Ambu bag in the 2B cart was expired, and the 1B cart contained two expired Ambu bags and expired Assure Prism glucometer strips. RN staff confirmed the items were expired and should not have been in the carts.
A gas stove in the kitchen had a back center burner that would not ignite when turned on, and staff reported it had been not working for about 1 to 2 months. Interviews showed cooks were expected to report equipment problems to the DM, who would notify Maintenance, but the issue was not promptly communicated to Maintenance. No gas odor or hissing was observed, and the burner was later taken out of service until repaired.
The facility failed to keep one of its elevators in safe operating condition. Records showed elevator two malfunctioned multiple times and needed a replacement part, and residents and staff were aware of the repeated malfunctions. The Administrator confirmed the elevator was malfunctioning and needed repair.
Failure to Maintain Dryer Lint Traps: Surveyors observed heavy lint buildup in both dryer lint traps, with lint hanging from each trap and covering the full trap surface. The sign-off log showed no entries after the prior shift, and staff interviews confirmed the required two-hour checks and documentation were not consistently completed.
Glucometer calibration and QC were not documented for one glucometer on Medication Cart D, and the QC log was blank for the scheduled check. LVN and DON verified that the 11-7 shift was responsible for nightly/daily calibration and QC to support accurate blood sugar readings.
Thermostats Not Powered On or Working: Two of five sampled thermostats were observed turned off with black screens and no visible power. A resident’s RP said it was always hot in the resident’s room and a fan was provided because there was no working AC. The MS stated the thermostats should be on and working to regulate room temperatures, but he was unsure how often they should be checked.
Expired Supplies Found in Crash Carts
Penalty
Summary
The facility failed to keep crash cart equipment in safe operating condition for two of two crash carts on nursing units 1B and 2B. The facility’s Emergency Equipment Check Policy stated that emergency equipment carts are to be checked daily, outdated or opened items are to be replaced, and contents are to be checked monthly for expired items if the cart is not accessed in the interim. During observation of the crash cart on 2B, an opened Ambu bag was found stored in the cart with an expired date, and RN E14 confirmed it was expired. During observation of the crash cart on 1B, two Ambu bags and a bottle of Assure Prism glucometer strips were found with expired dates, and RN E4 confirmed the Ambu bags and glucometer strips were expired and should not have been in the crash cart.
Kitchen Stove Burner Not Functioning
Penalty
Summary
The facility failed to maintain essential kitchen equipment in safe operating condition when the back center burner on the gas stove did not ignite when the knob was turned. During an observation and interview, the burner was checked and found not to light, and staff reported it had not been lighting for about 1 to 2 months. No gas odors or hissing sounds were observed in the kitchen, and the burner was later taken out of service until repaired. Staff interviews showed that cooks were expected to notify the DM when equipment was not working properly, and the DM was expected to notify the Maintenance Director and enter the concern into the electronic Maintenance reporting system. The Regional Director of Dietary Services stated the issue may have involved miscommunication between dietary and maintenance departments and said all dietary staff were educated to notify the DM with any equipment not working properly. The DM stated she had worked on the stove previously and thought the pilot light had gone out, while the Maintenance Director said he was not aware of the problem until it was brought to his attention. On a later observation, the same back middle burner still did not light immediately. A cook stated she was unsure whether water from eggs may have put out the pilot and said she had last seen it working a few days earlier. The Administrator stated he had only just been made aware that the stove had a burner not working, and the Maintenance Director had checked it and ordered a part to repair it. Record review also showed kitchen rounds documentation indicating the stove and oven were clean and equipment well maintained, along with facility policy stating that all staff should utilize the electronic Maintenance reporting system and that equipment repairs must be documented with a work order associated with the asset.
Elevator Malfunctioned and Remained in Need of Repair
Penalty
Summary
The facility failed to ensure that essential equipment was in safe operating condition for one of two elevators, specifically elevator two. Facility documentation showed that elevator two malfunctioned on June 14, 2026, and again on July 1, 5, and 21, 2026, and that a replacement part was needed. During interviews on July 31, 2026, Resident 1, Resident 2, and Employees 1, 2, 3, and 4 stated they were aware that elevator two had malfunctioned. In an interview on July 21, 2026, at 12:50 p.m., the Administrator confirmed that the elevator had malfunctioned and was in need of repair.
Failure to Maintain Dryer Lint Traps
Penalty
Summary
The facility failed to keep essential equipment clean and in safe operating order for 2 of 2 dryers observed in the laundry room. During a continuous observation on 07/31/2026, the surveyor and the Housekeeping Manager opened the dryer lint trap access panel and found copious amounts of lint in both dryer #1 and dryer #2 lint traps, with a visible sheet of lint hanging from each trap. The lint was removed with a broom and was observed to be approximately one quarter inch thick, in one piece, and covering the entire lint trap area, which measured about 16 inches by 20 inches. Review of the Dryer Lint Trap sign-off form showed the last entry was at 4:00 PM on 7/30/2026, with no initials or names entered after that time. The Housekeeping Manager stated the laundry aides were expected to check and remove lint from both dryers every two hours and sign the form, and Laundry Aide #1 stated she had not yet signed the form because she had been busy and could not remember the exact time she removed lint that morning. Laundry Aide #2 stated she worked the prior evening, forgot to sign the form, and removed lint before leaving, but also stated that if lint was hanging down, the traps likely had not been checked much that day. The Housekeeping Manager stated he did not think the amount of lint found was a safety concern, and the Administrator stated the lint traps should be checked for buildup of lint with instruction from the Housekeeping Manager.
Glucometer Calibration and Quality Control Not Documented
Penalty
Summary
The facility failed to ensure one of three glucometers, Glucometer A, was calibrated and that quality control was performed as scheduled on 7/27/26. Review of the EvenCare G2 User's Guide showed that control solution testing is used to make sure the EvenCare G2 Meter and EvenCare G2 Test Strips are working properly. Review of the Quality Control Record for Medication Cart D dated 7/2026 showed no documented evidence that the glucometer with serial number 48072751 was calibrated or had a quality control check, and the log was blank for 7/27/26. During a concurrent inspection of Medication Cart D on 7/28/26, LVN 7 verified the findings and stated that licensed nurses on the 11-7 shift calibrated the glucometer and performed quality control, and that the glucometers and quality controls were checked nightly to ensure accurate blood sugar level checks for residents. On 7/30/26, the DON also verified the findings and stated that glucometer quality control performance testing should be done daily on the 11-7 shift to ensure accurate blood sugar readings.
Thermostats Not Powered On or Working
Penalty
Summary
The facility failed to ensure two of five sampled thermostats were powered on and working. During an interview, a resident’s responsible party stated it was always hot in the resident’s room and that a fan was provided because there was no working air conditioning. During observation with the Maintenance Supervisor, two thermostats were seen turned off with black screens and no visible power. The Maintenance Supervisor stated the thermostats should be on and working so resident room temperatures were controlled and regulated to prevent residents from being too hot or too cold, but he was unsure how often the thermostats should be checked. The facility’s policy titled Thermostat and Indoor Temperature Control stated the facility shall maintain comfortable and safe temperature levels throughout all resident occupied areas.
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