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.
A resident with dementia and aphasia was identified as an elopement risk and had orders for a security bracelet and shift checks of placement. During observation, staff tested the bracelet at an exit door on the Delta pod and the keypad stayed green with no alarm, while another exit door and another resident's bracelet did trigger the alarm. The Maintenance Director could not explain why the resident's bracelet was not working on that door, and the DON and Administrator stated bracelets and doors were checked, but no log showed when the resident's bracelet was last tested against the door sensors.
Water heaters were not maintained in safe operating condition. The Maintenance Director confirmed that 1 of 4 tankless water heaters in multiple resident halls had been down for several weeks, with units turned off and labeled "Replace." Water temp checks had not been completed since May, and shower room temps were observed at 88.3°F, 103.3°F, and 84.7°F in different halls. The Administrator and Regional Compliance Nurse confirmed the missed checks and were unaware of the extent of the problem.
Dishwasher Not Maintaining Required Sanitizing Temperature: A dishwasher in the kitchen was observed running at 109 degrees while dishes were being washed, with a white substance bubbling at the dispensing spout. The Dishwasher Aide could not explain the substance and did not describe the dishwashing procedure. Records showed the machine was documented as meeting required wash, rinse, and sanitizer readings, but later observation found it took multiple cycles and still only reached 114 degrees, despite staff stating it should maintain at least 120 degrees.
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 kept in safe operating condition. Surveyors observed heavy carbon buildup on most burners of the gas range, two far-right burners that would not light automatically, and a right-side oven that repeatedly failed to heat properly. Kitchen staff said the oven often required food to be moved to the burners to finish cooking, and interviews showed the problems had been known to maintenance for weeks or longer, with no related work orders in the maintenance log.
Broken Bed Not Maintained in Safe Operating Condition: A resident with hemiplegia, osteoarthritis, and moderate cognitive impairment reported that her bed remote was hard to use and that the foot of the bed creaked and dropped suddenly when lowered. Staff gave inconsistent accounts about the issue, no current maintenance request was found, and the Maintenance Assistant observed the same malfunction during inspection. The DON acknowledged a gap in communication, and the facility policy required equipment to be kept safe and operable at all times.
In the laundry department, 1 of 2 commercial washers was out of service for more than 8 months, leaving only 1 washer available for resident laundry. Laundry Aides stated they used the working washer for all residents and that keeping up with timely laundry services was sometimes challenging with only 1 machine.
A facility failed to keep an electric Hoyer lift in safe working condition for residents who required Hoyer lift transfers. Staff used the lift interchangeably on the Sunset and Rodeo hallways even though its control box was cracked open with jagged edges, and a CNA reported the emergency mechanical lowering descent mechanism was also broken. The DON, Corporate, and Maintenance Director said they had not been notified, and maintenance logs showed no repair entries for the lift despite 18 residents being listed as needing Hoyer lift transfers.
Laundry equipment was not maintained in safe operating condition. A resident with ESRD on dialysis reported that clothes came back stinking, while the Laundry Supervisor said the industrial washer kept breaking down, hot water was not getting hot, the wrong soap was being used for resident clothing, and the department lacked a hopper for washing soiled linens. Observation showed a small washer overfilled with sheets, and staff gave mixed reports about washer breakdowns and linen shortages.
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