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.
The facility failed to maintain essential equipment and to follow its own maintenance request policy, affecting two residents and potentially many others. A resident with intact cognition was observed in a wheelchair with torn, cracked, and loose armrests after having reported the needed repairs to staff, yet the issue was not documented on the maintenance log. Another resident’s room lamp, previously logged as not working, remained nonfunctional when tested by the assistant administrator. The facility had no building manager for several weeks, and the assistant administrator and DON acknowledged that maintenance responsibilities were being covered without proper documentation, as most entries on the maintenance log lacked recorded actions for issues such as a nonworking mechanical lift, malfunctioning call light, bed and wheelchair problems, and other equipment concerns.
The facility failed to maintain functional handicap door push buttons at the main entrance and did not ensure timely reporting or documentation of malfunctions. A family member and front desk staff reported that a main entrance handicap button had not worked for months, and maintenance staff confirmed that all three front entrance buttons were inoperable during a surveyor inspection, despite a resident who uses a motorized wheelchair reporting intermittent function. Surveyors repeatedly found the outside front entrance button nonfunctional even after reported repairs, while maintenance logs documented door checks but did not specifically include the handicap buttons, and routine checks were not completed as stated in the facility’s preventative maintenance policy.
The facility failed to maintain an adequate supply of working batteries for mechanical lifts, causing delays and difficulties in transferring a resident who required a Hoyer lift for all transfers and needed timely transport to dialysis. CNAs reported that lift batteries were often dead, that they had to leave the unit to search for batteries, and that typically only one or two batteries were available for all halls. The Administrator confirmed there were more lifts than batteries, that some batteries needed fuses, and that there was no specific equipment maintenance policy, despite an expectation to follow manufacturer guidelines.
The facility failed to maintain functional laundry equipment, leaving only one working washer and two non-functioning washers, along with an out-of-order dryer, which significantly reduced laundry capacity for linens and residents’ personal clothing. A RN and an LPN reported ongoing resident complaints about laundry after a washer broke, and the Housekeeping Director confirmed that only one machine was handling both linens and personal clothes, with frequent need to order extra linens. The Maintenance Director described long-standing, poorly maintained machines with rust, holes, and a jammed door trapping linens inside, and acknowledged that only a fraction of the normal wash capacity was available. Several residents, including one with bed sores and another with chronic diarrhea, reported not having enough clean linens, having unchanged sheets, needing to hold onto their own towels, or paying outside services to wash their clothes due to the lack of facility-provided laundry.
Essential heating equipment was not properly maintained following a power outage, resulting in a period without adequate heat for all residents. The Maintenance Director did not know the boilers required manual resetting after the outage and did not reset all units, and an assistant later had to reset an additional boiler. A heating contractor identified a failed pump motor that was critical for the heat pumps to function and advised immediate replacement, but facility leadership chose to delay the work until normal business hours, despite staff reporting that they were cold. A technician later replaced the defective pump motor and components and confirmed that room temperatures were rising.
A resident with full-code status and significant cardiopulmonary conditions was found unresponsive, and an LPN initiated CPR while another LPN retrieved the crash cart and attempted to use the AED. The AED repeatedly announced a low battery and no pads could be found on the crash cart, so the AED could not be applied while staff continued manual compressions until EMS arrived. Interviews revealed that only one crash cart was available, the ADON was responsible for monthly checks, and the crash cart checklist did not include the AED. Staff reported the AED had been announcing a low battery for several months, the last set of pads had been used in a prior code and not replaced, and leadership, including the administrator and owner, were aware of the low battery but had not ensured timely ordering of a replacement battery and pads. The AED manufacturer’s manual required regular status checks and battery replacement when low, and facility policies required the emergency cart to be inventoried after each use, checked at least monthly with documentation, and to maintain CPR/BLS equipment at all times, while multiple residents in the facility had active CPR orders.
Several cognitively intact residents with complex medical needs were unable to access hot water for bathing over multiple days due to malfunctioning water heaters. During this period, residents were either given cold showers, wet wipe baths, or had to refuse bathing, with no consistent alternative provided. Staff and maintenance confirmed the hot water shortage and equipment failure, which impacted the facility's ability to meet residents' basic needs.
A resident with multiple pressure ulcers and complex medical needs experienced extreme pain due to a malfunctioning low air loss mattress that repeatedly lost inflation, leaving her on a hard bed frame. Staff and family reported the issue, and photographic evidence confirmed the mattress was not maintained in safe working order, despite care plan requirements and facility policy.
The facility did not maintain full mechanical lifts in safe working order, as several lifts were found to be nonfunctional, with broken emergency releases and makeshift repairs such as adhesive tape. Staff and residents reported frequent problems, and maintenance did not perform routine checks or receive work orders for these issues, resulting in continued use of unsafe equipment for multiple residents requiring lift assistance.
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