Unsafe Shower Chairs with Ineffective Brakes Used During Resident Transfers
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.
Penalty
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The facility failed to keep a kitchen dishwashing system in good working order when surveyors observed water flowing from a metal device under the counter, with buckled tile and peeled-back wall trim nearby. A kitchen staff member said maintenance had known about the leak for about a month, and maintenance later confirmed the issue had not been reported through the TELS system and that the damage was not new.
Lint Buildup in Dryer Lint Trap: One of two dryers was observed running with lint buildup in the lint trap after the lint door was opened during a laundry tour. The MSS stated the lint trap should be cleaned every 2 hours for fire safety, and an LA stated she forgot to clean Dryer 2's lint trap. Facility policy required laundry equipment to be maintained per manufacturer instructions and kept in a safe, operable condition.
Essential kitchen equipment was not kept in good working condition. A large kitchen refrigerator had standing water on the bottom shelf and water dripping from the top onto covered food, and a resident refrigerator freezer had heavy ice buildup with a splintered gasket that did not attach well. The ADON and Maintenance Director both verified the equipment problems, and the MD stated the refrigerator was not working properly and needed repaired.
Dishwasher Thermometer Inaccurate and Temps Below Required Level: The low-temp dishwasher was observed with wash and rinse temps below the facility's required 120F minimum, and the DS stated staff had to handwash dishes while the machine was out of order. The MS later found the machine's thermometer was not reading accurately, with the manual thermometer showing 135.1F while the machine read 118F, and the DS said the length of time the thermometer had been inaccurate was unknown.
Kitchen equipment was not maintained in safe operating condition. A plate warmer was plugged in but only held room-temperature plates, and staff said it had not warmed plates since the prior week or earlier. A dishwasher temperature gauge was also faulty, reading 110F while a separate gauge showed the water was 122F during operation. The Maintenance Director said he had not been notified of either issue and found no June maintenance entries for the plate warmer or dishwasher gauge.
Kitchen equipment was not maintained in proper working order, affecting nearly all residents who received meals from the kitchen. Surveyors observed significant ice buildup in two reach-in freezers, including on food products, and found the garbage disposal covered. Dietary staff said the disposal had been broken for about a year, and the DM reported the freezers were constantly in defrost with possible door seal problems. Maintenance confirmed the disposal needed replacement and said approval was delayed because the facility was being sold.
Kitchen Dishwashing System Leak Not Maintained
Penalty
Summary
The facility failed to maintain equipment in good working order for one kitchen dishwashing system and the surrounding area. During an initial kitchen tour, surveyors observed dishwater and a metal device underneath the counter with a large amount of water flowing from it, along with a buckled tile floor and peeled-back trim around the perimeter of the wall. A kitchen staff member stated maintenance had known about the water leak for about a month. When maintenance reviewed the area, the water was turned off, and maintenance stated staff are expected to report needed repairs through the TELS system, but the issue had not been reported. Maintenance confirmed the damage was not new and should have been reported sooner, and stated a plumber would be coming to assess the leak. The administrator later confirmed the expectation that staff use the TELS system for items needing repair and stated they had been updated that a plumber had been called.
Lint Buildup in Dryer Lint Trap
Penalty
Summary
Essential laundry equipment was not maintained in safe operating condition when one of two dryers was found operating with lint buildup in the lint trap. During a laundry tour, Laundry Aid 1 opened the lint door underneath Dryer 2 and observed lint buildup on the lint trap while the dryer was running without any items inside. The Maintenance Service Supervisor stated the dryer lint trap should be cleaned every 2 hours for fire safety and prevention, and Laundry Aid 2 stated she forgot to clean the lint trap of Dryer 2 at 2 PM and that the dryer should be regularly cleaned and free from lint buildup. Facility policy for Laundry stated equipment will be used and maintained according to manufacturer instructions, and the Preventative maintenance program policy stated the maintenance director is responsible for maintaining a schedule so buildings, grounds, and equipment are kept in a safe and operable manner.
Kitchen Refrigeration Not Maintained in Working Condition
Penalty
Summary
Essential kitchen equipment was not maintained in good working condition. During an initial kitchen tour and a later observation, the large three-door refrigerator had one quarter to one half inch of standing water on the bottom shelf and water dripping from the top, and bags of food were wet from the dripping water. On the 200 unit, a resident refrigerator freezer had a heavy one half inch build-up of white ice on the top and side surfaces, and the gasket around the freezer was splintered and did not attach well to the compartment. An ADON verified the freezer gasket was in disrepair and did not attach well, and the Maintenance Director verified the kitchen refrigerator had standing water in the bottom, water dripping from inside the top onto covered food, and that the refrigerator was not working properly and needed repaired. The facility policy stated maintenance would attempt repairs and use outside contractors if unable to complete them.
Dishwasher Thermometer Inaccurate and Temperatures Below Required Level
Penalty
Summary
The facility failed to maintain the dishwashing machine in safe operating condition. During observation and interview, the Dietary Supervisor stated the low-temperature dishwasher was required to log wash and rinse temperatures of at least 120 degrees Fahrenheit to properly clean dishware. When the machine was run three times, the recorded temperatures were below that level, with wash temperatures of 110 degrees Fahrenheit on all three runs and rinse temperatures of 110, 110, and 112 degrees Fahrenheit. The Dietary Supervisor stated the machine was not reaching the goal temperature and that staff had to use the two-compartment sinks to handwash dishes while the machine was out of order. During interview and observation, the Maintenance Supervisor manually checked the dishwasher water temperature and found the manual thermometer read 135.1 degrees Fahrenheit while the dishwasher's thermometer read 118 degrees Fahrenheit. The Maintenance Supervisor stated the dishwasher thermometer was not reading accurately. The Dietary Supervisor stated she did not know how long the thermometer had been inaccurate, but the last inspection by the dishwasher company had been on 6/16/26. The facility policy for chemical low-temperature dish machines stated they must maintain a water temperature of 120F to 140F.
Kitchen Equipment Not Maintained in Safe Operating Condition
Penalty
Summary
The facility failed to maintain essential kitchen equipment in safe operating condition. During an observation and interview, the kitchen's electrical plate warmer was plugged into the outlet but contained room-temperature plates, and the FSM and another staff member stated it had not warmed plates since the prior week or possibly earlier. The FSM said the plate warmer had been entered into the facility's maintenance care program, which was supposed to alert the Maintenance Director to the needed repair. During another observation and interview, the kitchen dishwasher's temperature gauge read 110F during operation and after operation, while the FSM used a separate temperature gauge and demonstrated that the water temperature during operation was 122F. The FSM stated that the safe operating temperature was over 120F and identified the dishwasher gauge as faulty. The Maintenance Director later stated he had not been notified of the faulty kitchen equipment and found no June 2026 maintenance entries for either the plate warmer or the dishwasher gauge in the maintenance care database. A record review of the facility's preventive maintenance policy stated that the facility would maintain a comprehensive preventive maintenance program for essential operating equipment and document all preventive maintenance.
Kitchen Equipment Not Maintained in Working Order
Penalty
Summary
The facility failed to maintain kitchen equipment in proper working order, affecting all 39 residents who received food from the kitchen except one resident who had orders for nothing by mouth. Maintenance records showed dietary staff reported the garbage disposal was not working on 07/21/25, but the work order was not set to completed until 08/29/25. A repair quote dated 03/11/26 showed the garbage disposal needed replacement. During an observation on 06/15/26, surveyors found reach-in freezer #1 and reach-in freezer #2 had significant ice buildup, including on food products, and the garbage disposal had a cover over it. Dietary staff confirmed the ice buildup and stated the garbage disposal had been broken for about a year and the facility did not want to pay to fix it. The Dietary Manager stated the two reach-in freezers were constantly in a state of defrost and believed there was something wrong with the door seals. The Maintenance Director confirmed the garbage disposal needed replacement and stated the quote was not approved until 06/15/26 because the facility was being sold.
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