F0908

F

Failure to Maintain Ice Machine and Provide Ice for Residents

Riverbank, California Survey Completed on 03-23-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to maintain essential equipment in safe operating condition when the only ice machine malfunctioned and residents were left without ice for two consecutive days. Staff interviews and observations on 3/23/26 confirmed that the ice machine stopped dispensing ice on Friday 3/20/26 and that no ice was available for residents on 3/21/26 and 3/22/26. The facility’s own policy stated that ice machines and ice storage/distribution containers would be used and maintained to assure a safe and sanitary supply of ice, and the manufacturer’s guidelines specified that equipment should not be operated when damaged or not in original manufactured condition. Despite these requirements, the ice chute/dispenser on the aging ice machine repeatedly came off track, preventing ice from being dispensed, and no alternative ice supply was provided over the weekend.

Two cognitively intact residents reported not having ice and described how this affected their fluid intake. One resident with an indwelling catheter, neuromuscular dysfunction of the bladder, pressure ulcer, protein-calorie malnutrition, and paraplegia stated she had not received any ice since Friday and that she preferred ice-cold drinks; her cup was observed to be empty, and she reported she did not consume as much fluid as usual because there was no ice. Her roommate, who had diagnoses including cerebral palsy, malignant neoplasm of the breast, and bipolar disorder, also reported there was no ice to drink over the weekend, stated she had a recent UTI and needed to drink fluids to help prevent another infection, and requested a soda with ice when ice finally became available. Both residents’ MDS assessments showed BIMS scores in the cognitively intact range.

Multiple staff members confirmed the lack of ice and described the usual process and the breakdown in communication and follow-up. CNAs reported there was no ice over the weekend, that residents complained about the lack of ice, and that ice was normally kept in chests at the nurses’ station and changed once per shift. An LVN stated there was no ice available when she passed medications on Saturday and emphasized that some residents would not drink as much fluid if it was not cold. Dietary staff, including the Certified Dietary Manager and cooks, stated the ice machine dispenser had come off track, that there was no ice in the kitchen freezers, and that no one contacted dietary leadership over the weekend. The Director of Maintenance acknowledged the ice machine was old and had acted up off and on, that he had previously realigned the dispenser on 3/19/26, and that he received a text on 3/20/26 about the machine not working but assumed the issue was resolved because he received no further communication. The Administrator, DON, MDS Coordinator, and payroll staff each reported they were not effectively notified or did not follow up after receiving notice, resulting in residents having no access to ice for two days and the facility failing to maintain the ice machine in safe operating condition.

The facility’s own documentation from 3/19/26 noted that the ice chute had fallen off track, likely due to pushing too hard on the lever, and the manufacturer’s manual described that ice falls from the paddle wheel to the ice chute opening of the dispenser bin and that damaged or altered equipment should not be operated. Despite this known, recurring problem with the dispenser coming off track, the ice machine remained the sole source of ice, and no interim measures were implemented when it failed again over the weekend. Staff interviews, resident statements, and record review collectively demonstrate that the facility did not ensure continuous availability of ice or timely repair/alternative provision when the ice machine malfunctioned, creating a lapse in maintaining essential equipment in safe operating condition as required by facility policy and manufacturer guidelines.