South Coast Global Medical Center D/P SNF

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure four of four residents (Residents 8, 12, 14, and 25) reviewed for accidents remained free from accident hazards. * The facility failed to ensure both side rails were padded for Resident 8, as per the physician's order and as care planned for Resident 8, due to the risk of injury from their seizure disorder. * The facility failed to ensure Resident 12's bilateral side rails were used as per the physician's order and failed to ensure Resident 12's bed was in the lowest position to prevent/minimize any injuries in the event Resident 12 had a seizure episode. Additionally, the facility failed to ensure two staff members assisted in the transfer of Resident 12 from the shower gurney back to the bed as per the facility's P&P. [...]

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary respiratory services for four of four sampled residents (Residents 7, 10, 12, and 25) reviewed for respiratory care. * The facility failed to ensure Resident 7's ventilator circuit set-up and in-line suction catheter changes were done as per the physician's orders. * The facility failed to ensure Resident 10's ventilator high-pressure alarm was set within a safe parameter. * The facility failed to ensure Resident 12 's oxygen flowmeter was set to the appropriate liter flow to match the aerosol mist setting as per the physician's order. In addition, the facility failed to ensure the flowmeter was in working condition. * The facility failed to provide Resident 25 continuous oxygen therapy during the transfer from a Geri-chair to his bed using a Hoyer lift. [...]

Inspectors wroteBased on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to implement their infection control program in accordance with the facility's P&P. * The facility failed to implement their infection control surveillance program from August 2025 through December 2025. The facility conducted surveillance of resident infections based on whether the residents were prescribed antimicrobial medications. The facility failed to determine whether the residents who exhibited signs and symptoms of infection and were not prescribed antimicrobial medications met the facility's criteria for infection (utilizing McGeer's Criteria). The facility failed to include these residents in the facility's infection control surveillance program. [...]

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure care was provided in a manner which promoted dignity and respect for two of 14 final sampled residents (Residents 5 and 6). * The facility failed to ensure Resident 5 and 6's urinary output drainage bags were stored inside of the privacy bag. This failure had the potential to compromise Resident 5 and 6's rights to be treated with respect and dignity.

Inspectors wroteBased on observation and interview, the facility failed to maintain a homelike environment for four of 14 final sampled residents (Residents 5, 12, 14, and 25). * Resident 5 resided in Room C. The emergency outlet on the wall behind Resident 5's head of bed was observed in disrepair with chipped paint, wall debris and an opening above the red wall plate and the wall. * Resident 12 resided in Room A. The wall at the foot of Resident 12's bed was observed in disrepair with chipped paint and unpainted areas. * Residents 14 and 25 resided in Room B. The walls behind the residents' beds were observed in disrepair, as evidenced by scratches, chipped drywall, and peeled paint. These failures had the potential to negatively impact the residents' quality of life.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure one of five final sampled residents (Resident 18) reviewed for unnecessary medications were free from unnecessary psychotropic medications. * The facility failed to ensure Resident 18's orthostatic BP was monitored for the use of the Seroquel (antipsychotic medication). * The facility failed to ensure Resident 18's nonpharmacological interventions and its effectiveness were documented for the documented observed behaviors related to the use of the Zoloft (antidepressant medication). These failures had the potential for Resident 18 to experience potential harm from the adverse consequences from the use of the Seroquel medication and prevented the facility from accurately monitoring the effectiveness of the behavioral interventions in an effort to discontinue the use of the Zoloft medication.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the comprehensive care plan was implemented for three of 14 final sampled residents (Residents 14, 22 and 8). * The facility failed to ensure Resident 8's side rails were padded in accordance with the resident's plan of care. * The facility failed to ensure Resident 14's side rails were padded and the bilateral heel protectors were applied in accordance with the resident's plan of care. * The facility failed to ensure Resident 22's bilateral heel protectors were applied while in bed in accordance with the resident's plan of care. These failures placed the residents at risk for injuries and not being provided with the appropriate, consistent, and individualized care.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the necessary care and services were provided to prevent the development of pressure injuries, for three of five sampled residents (Residents 5, 14, and 22) reviewed for pressure ulcers. * The facility failed to ensure the bilateral heel protectors were applied while Residents 5, 14, and 22 were in bed as per the physician's orders. These failures had the potential for the residents to develop pressure injuries.

Inspectors wroteBased on observation, interview, medical record review, and P&P review, the facility failed to provide RNA services per the physician's order for one of 14 final sampled residents (Resident 3). * Resident 3 did not receive RNA services per the physician's order. This failure had the potential for Resident 3's upper body contractures and range of motion (ROM) to worsen.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services to maintain the IV access for one of one final sampled resident (Resident 5) reviewed for IV care. * The facility failed to ensure Resident 5's peripheral IV dressing on the left lower extremity was labeled with the date and initials and a care plan was developed for the use and maintenance of Resident 5's peripheral IV. In addition, the facility failed to ensure the insertion and/or removal of the peripheral IV and daily assessment of the peripheral IV site were documented. These failures had the potential to delay the identification of catheter related complications for Resident 5.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the medication error rate was below five percent. The facility's medication error rate was 7.69% * Resident 8 had a physician's order for amlodipine 5 mg daily via GT for hypertension (high BP). The order showed to hold the medication if Resident 8's SBP was less than 100 mmHg. However, the licensed nurse held the medication when Resident 8's SBP was not less than 100 mmHg. This failure to administer the antihypertensive medication in accordance with the physician's order had the potential to result in negative health outcomes. * Resident 8 had a physician's order for liquid potassium chloride 10 mEq daily via GT for hypokalemia. [...]

Inspectors wroteBased on observation, interview, and facility P&P review, the facility failed to ensure two of four medication carts were clean. * Medication Carts A and B were observed with unclean containers. The unclean containers contained lancets, alcohol pads, insulin syringes, and a pill splitter. This failure to maintain the medication carts in a sanitary condition posed the risk for negative residents health outcomes.

Inspectors wroteBased on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure the food safety and sanitation requirements were met in the kitchen. * The facility failed to ensure the proper labeling of food in the freezer. * The facility failed to ensure the kitchen utensils and equipment were stored or kept in sanitary conditions. * The facility failed to ensure the kitchen utensils were in good condition. * The facility failed to ensure the kitchen utensils were air-dried. * The facility failed to ensure the item in the kitchen was discarded after the use-by date. * The facility failed to ensure proper sanitary condition of the ice machine. These failures had the potential for exposure to food-borne illnesses for a medically vulnerable population.

Inspectors wroteBased on interview and medical record review, the facility failed to ensure the medical record for one of 14 final sampled residents (Resident 5) was accurate. * The facility failed to ensure Resident 5's POLST was complete. This failure had the potential for the resident's care needs not being met as the medical information was inaccurate.

Inspectors wroteBased on interview and medical record review, the facility failed to ensure the MDS assessment was completed accurately for one of 14 final sampled residents (Resident 18). * The facility failed to ensure the section for Resident 18's gradual dose reduction (GDR) was coded correctly in the resident's quarterly MDS assessment. This failure had the potential risk of the resident not receiving the individualized plan of care based on the resident's specific needs.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure the comprehensive care plan was revised for one of 14 final sampled residents (Resident 7). * The facility failed to ensure Resident 7's comprehensive care plan was revised to reflect a physician's order for changing the ventilator circuit-set up every two weeks and as needed if visibly soiled or malfunctioning. This failure posed the resident at risk for not being provided with the appropriate, consistent, and individualized care.

Inspectors wroteBased on observation, interview, and facility P&P review, the facility failed to ensure the residents' PHI was kept confidential for 27 residents. All 27 residents' PHI was displayed on a computer screen and left unattended by the staff member. This failure had the potential to violate the residents' rights to PHI privacy.

Inspectors wroteBased on interview and facility document review, the facility failed to ensure the Facility Assessment addressed or included the following: 1. Active involvement of required individuals in developing the Facility Assessment; 2. Resources necessary to care for residents including weekends; 3. Include a plan to maximize recruitment and retention of direct care staff; and 4. Include a contingency plan for staffing needs. This failure placed the residents at risk for unmet care needs if their assessed population's needs and resources were not comprehensively identified and addressed.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to notify three of three residents (two final sampled residents, Residents 2 and 27 and one nonsampled, Resident 17) reviewed for hospitalization of their rights to a bed hold (holding or reserving a resident's bed while the resident in the acute care hospital) policy upon transfer to the acute care facility in writing. This failure had the potential for the residents and/or their representatives to be unaware of their rights to request a bed hold upon transfer.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the necessary respiratory care and services were provided for seven of 13 final sample residents (Residents 2, 6, 8, 18, 26, 27, and 28). * The facility failed to ensure Resident 18's Trach Bar (T-Bar) aerosol tubing set-up was labeled with the date. * The facility failed to ensure Resident 26's yanker was labeled with the opened date and changed per the facility's P&P; and failed to ensure the T-Bar aerosol set-up was labeled with the date. * The facility failed to ensure Resident 28's T-Bar aerosol tubing set-up was labeled with the date; failed to ensure the sterile water connected to the oxygen flowmeter was labeled with the opened date; and failed to ensure the yanker was changed per the facility's P&P. [...]

Inspectors wroteBased on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to implement their infection control program and practices designed to provide a safe and sanitary environment to help prevent the transmission of communicable disease and infections. * The facility failed to maintain an accurate infection control surveillance program for October 2024 through December 2024. The facility failed to ensure the Surveillance Data was complete and accurate to determine whether the resident's infection met the McGeer's criteria for true infection. [...]

Inspectors wroteBased on interview, facility document review, and facility P&P review, the facility failed to implement an antibiotic stewardship program to reduce the risk of unnecessary or inappropriate antibiotic use. Residents were being treated for conditions which did not meet the McGeer's criteria (a surveillance data collection tool used in long-term care facilities to identify if residents' symptoms meet the criteria of a true infection). This had the potential to expose the residents to unnecessary antibiotic use, which may increase the residents' risk for multidrug resistant organisms (MDRO, germs that are resistant to many antibiotics).

Inspectors wroteBased on observation, interview, and facility P&P review, the facility failed to maintain a clean, safe, and homelike environment for one of 13 final sampled residents (Resident 26). Multiple dry and brown colored residues were observed on Resident 26's enteral feeding pump device. This failure had the potential to negatively impact the resident's safety and quality of life.

Inspectors wroteBased on interview and medical record review, the facility failed to notify the resident and/or their representative of the transfer/discharge and the reasons for the transfer in writing for one of three final sampled residents (Resident 2) reviewed for hospitalization. This failure had the potential for the resident and/or their representative not knowing about the appeal process should the resident and their representative believe the transfer or discharge was inappropriate or involuntary.

Inspectors wroteBased on interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure the PASRR (a federal requirement to help ensure that individuals are not inappropriately placed in nursing homes for long term care) Level 1 assessment was coded inaccurately for one of one final sampled resident reviewed for PASARR (Resident 26). This failure had the potential for having residents that were not appropriate in the facility and for Resident 26 not to receive the appropriate services.

Inspectors wroteBased on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure the low air loss mattress (pressure redistributing support surface) was set appropriately according to the resident's weight for one of three final sampled residents (Resident 24) reviewed for pressure ulcer (skin injury caused by prolonged pressure on an area of the body). This failure had the potential for Residents 24 not receiving the appropriate care and services to promote healing or prevent the development of the pressure ulcers.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide the RNA services as ordered by the physician for two of four final sampled residents reviewed for limited ROM (Residents 2 and 18). This failure had the potential for the residents' decline in ROM functions and deterioration in their ability to perform ADL care.

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to ensure one of 13 final sampled residents (Resident 11) remained free from accident hazards. * The facility failed to ensure Resident 11 had a helmet protective device when out of bed per the physician's order. This failure had the potential risk for injury to Resident 11.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary GT care and services for two of two sampled residents (one nonsampled resident, Resident 12 and one final sampled resident, Resident 18) reviewed for GT care. * The facility failed to ensure the licensed staff elevated Resident 12's HOB at 30 degrees to 45 degrees prior to the administration of medications via GT. * The facility failed to ensure Resident 18 was administered the enteral feeding as per the physician's orders and failed to ensure Resident 18's water flush was labeled with Resident 18's name and the ordered rate. These failures had the potential to negatively impact the residents' well-being.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the pharmaceutical services were provided to meet the needs for two final sampled residents (Residents 23 and 2). * The facility failed to ensure the physician's orders for Residents 23 and 2 were accurate. The medication route was ordered to be oral instead of GT. This failure had the potential for the medications to be administered in errors.

Inspectors wroteBased on interview, medical record review, and facility P& P review, the facility failed to ensure one of five final sampled residents (Resident 2) reviewed for unnecessary medications was free from the unnecessary psychotropic medications. * The facility failed to ensure the PRN order for the psychotropic medication was limited to 14 days for Residents 2. This failure had the potential to result in unnecessary use of, ineffective and/ or lack of monitoring or interventions for the use of the psychotropic medication that could negatively affect Resident 2 highest practicable mental, physical, and psychosocial well- being.

Inspectors wroteBased on observation, interview, and facility P&P review, the facility failed to ensure one of four medication carts (Medication Cart B) was properly locked and secured when unattended. This failure had the potential for unauthorized persons having access to the medications kept inside the medication cart.

Inspectors wroteBased on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the cook followed the recipe when preparing the puree Swiss steak. This failure had the potential of not meeting the residents' nutritional needs which could lead to nutritional related health complications.

Inspectors wroteBased on observation, interview, and facility document review, the facility failed to ensure the food safety and sanitation guidelines were followed when: * The facility failed to ensure a tray and a red blender were not stored wet. * The facility failed to ensure a rack for pots and pans were in a sanitary condition. * The facility failed to ensure four cutting boards were not heavily marred. These failures had the potential to result in foodborne illnesses for the residents receiving kitchen services in the facility.

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to ensure the medical record for one of 13 final sampled resident (Resident 26) was accurate and complete. * The facility failed to ensure Resident 26's Restraint Assessment/Restraint Flowsheet was complete. This failure had the potential for Resident 26's care needs not being met as their medical information was inaccurate.

Inspectors wroteBased on interview, medical record and the facility P&P review, the facility failed to ensure the resident's personal belongings were properly recorded for one of the two sampled residents (Resident 1). This failure had the potential for residents personal belongings being lost.

Inspectors wroteBased on observation, interview and medical record review, the facility failed to provide the necessary care and services to ensure four of four sampled residents (Residents 1, 2, 3, and 5) maintained good grooming, personal hygiene, and transfers for dependent residents. These failures had the potential for the residents to experience physical discomfort, emotional distress, health complications, and a decreased quality of life. * Resident 1 did not received shower as scheduled and was not transferred out of bed as scheduled. * Resident 2 did not received shower as scheduled and has long fingernails. * Resident 3 did not received shower as scheduled and was not transferred out of bed as scheduled. * Resident 4 had long fingernails.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to implement the plan of care to reflect the individual needs for one of 14 final sampled residents (Resident 23) and one nonsampled resident (Resident 9). * Resident 9's care plan intervention of padded side rails was not implemented by the facility staff. * Resident 23's DNR code status was not included in the resident's comprehensive care plan. * Resident 23's care plan intervention of padded side rails was not implemented by the facility staff. These failures posed the risk of not providing appropriate, consistent, and individualized care to the residents.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the necessary care and services were provided to prevent the development of new pressure ulcers (areas of damaged skin caused by staying in one position for a long time which reduces blood flow to the area and causes the skin to die and develop a sore) and promote healing of existing pressure ulcer for one of final 14 sampled residents (Resident 32). * The facility failed to ensure Resident 32 was turned and repositioned at least every two hours as per the physician's order and plan of care. This failure put Resident 32 at risk for developing new pressure ulcers and worsening of the existing pressure ulcer on the sacrococcygeal (the tailbone) area and MASD (moisture-associated skin damage; [...]

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to ensure two of 14 final sampled residents (Residents 1 and 18) and one nonsampled resident (Resident 9) remained free from accident hazards. * The facility failed to ensure Resident 9's side rails were padded as ordered by the physician and as care planned. * The facility failed to ensure two staff members assisted in obtaining Resident 1's weights. * The facility failed to ensure Resident 18's bilateral side rails were padded as per the resident's physician's order and care plan. These failures had the potential to place the residents at risk for serious injury.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the appropriate care and services for the use of G-tube (a small tube placed through the abdominal wall into the stomach, used to provide enteral feedings and/or administer medications; gastrostomy tube) for two of 14 final sampled residents (Residents 1 and 23) and one nonsampled resident (Resident 19). * The facility failed to ensure the licensed staff managed the G-tube feeding for Resident 1. CNA 1 had put the G-tube feeding on hold to provide incontinence care for Resident 1. In addition, RNA 1 had put the G-tube feeding on hold and resumed G-tube feeding after obtaining Resident 1's weight. * The facility failed to ensure Resident 23's tube feeding bag was labeled with it's contents. [...]

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the appropriate care and services for IV therapy (the administration of fluids or medications through an IV catheter) for two of 14 final sampled residents (Residents 1 and 2). * The facility failed to label Residents 1 and 2's IV medication tubing with the date or time when it was hung. This failure posed the potential risk for infection or phlebitis (inflammation of a vein) for Residents 1 and 2.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary respiratory care for one of 14 final sampled residents (Resident 18) and two nonsampled residents (Residents 6 and 16) with tracheostomy (breathing tube inserted through the neck into the airway to maintain an open airway). * The facility failed to ensure Residents 6 and 18's oxygen flow meters were set to the appropriate liter flow to match their aerosol mist setting as per physician's orders. * The facility failed to ensure the necessary respiratory care provided to Resident 16 was performed by a designated trained or licensed healthcare member. These failures had the potential for these residents to not receive appropriate respiratory care to negatively affect the residents' medical conditions.

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to ensure the appropriate and least restrictive measures of the side rail use were attempted for four of 14 final sampled residents (Residents 2, 23, 30 and 31). * Resident 2 and 31's medical records failed to show the outcome of least restrictive attempt prior to side rail use. * Resident 23 and 30's medical records failed to show the outcome of least restrictive attempt prior to side rail use and documentation of recent seizure activity for which the side rails were ordered. These failures had the potential to put the resident at risk of injury including entrapment.

Inspectors wroteBased on interview and medical record review the facility failed to ensure one of 14 final sampled residents (Resident 12) was free from the unnecessary medications (Resident 12). * The facility failed to monitor orthostatic hypotension for Resident 12 who was on quetiapine, an antipsychotic (reduce or relieve symptoms such as delusions (false beliefs) and hallucinations (seeing or hearing something that is not there) medication. This posed the risk of not identifying the potential harmful side effects associated with the medication and a delay in necessary medical interventions for this resident.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the residents' medications were stored properly for one of 14 final sampled residents (Resident 5) and one nonsampled resident (Resident 16), and in two of five medication carts (Medication Carts A and B). * The facility failed to ensure the topical medication was stored properly for Resident 5 when a tube of triamcinolone ointment (a topical ointment used to relieve redness, itching, swelling, or other discomfort caused by skin conditions) was observed on Resident 5's bedside table. * The acetylcysteine (a medication used to help thin and loosen mucus in the airways due to certain lung diseases) and Refresh eye drop (lubricating eye medication to relieve dry eyes) medications were left at Resident 16's bedside. [...]

Inspectors wroteBased on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the kitchen staff had the appropriate skill sets to safely perform the daily operation of the Food and Nutrition Services Department. * [NAME] 1 was unable to perform the thermometer calibration as per the facility's P&P. This had the potential for inaccurate food temperature readings and could lead to foodborne illnesses in a highly susceptible populations of residents who received food preparation in the kitchen.

Inspectors wroteBased on observation, interview, and facility P&P review, the facility failed to ensure the sanitary requirements were met in the kitchen as evidenced by: * The facility failed to ensure the cutting boards were kept in a sanitary condition. * The facility failed to ensure a safe working area was provided for staff in the dishwashing room when puddle of water was observed on the floor, which was from the broken hot water booster for the dishwasher. * The facility failed to ensure the proper labeling with open date or use by date of the bacon and sausage stored in the kitchen refrigerator. * The facility failed to ensure the kitchen refrigerator shelves were clean. * The facility failed to ensure the freezer was free from any ice buildup. * The facility failed to ensure the expired food items in the kitchen were discarded. [...]

Inspectors wroteBased on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure the residents' entrapment assessments were accurate, complete; and the measurements were recorded during the bed inspection when identifying areas of possible entrapment with the use of bed side rails for six of 14 final sampled residents (Residents 2, 13, 18, 23, 30, and 32) and one nonsampled resident (Resident 19). * The facility failed to ensure Resident 13's bed entrapment assessment was completed with bed inspection gap measurements. * The facility failed to ensure Resident 18's bed entrapment assessment was completed with bed inspection gap measurements. * The facility failed to ensure Resident 19's bed entrapment assessment was completed with bed inspection gap measurements. [...]

Inspectors wroteBased on interview and medical record review, the facility failed to ensure the physician's orders for code status matched the residents' POLST DNR status for one of 14 final sampled residents (Resident 23) and one nonsampled resident (Resident 16) * The facility failed to ensure the physician's orders for code status matched the Physician Orders for Life-Sustaining Treatment (POLST) form signed by the residents/residents' representatives for Residents 16 and 23. Residents 16 and 23 had DNR status selected on the POLST; however, the physician's orders showed the full code. This failure had the potential for not honoring the resident's wishes and providing unwanted life sustaining interventions.

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to ensure the comprehensive plan of care for one of 14 final sampled residents (Resident 18) was revised to reflect the residents' current care needs and interventions. * Resident 18's care plan for hand mittens was not revised to address the current left hand mitten order. This posed the risk of not providing the resident with individualized and person-centered care.

Inspectors wroteBased on interview and medical record review, the facility failed to ensure the facility's arbitration agreement (an agreement between the facility and resident or resident representatives where they would resolve any disputes through a neutral person, rather than through court), specifically provided for the selection of a neutral arbitrator (an impartial, or unbiased third-party decision maker, agreed to by both parties to resolve their dispute) and selection of a venue (a location to carry out the arbitration proceedings that was agreed upon by both parties) that was convenient for the residents and/or their representatives. These failures had the potential for residents to be uninformed and negatively affect the ability to resolve any disputes.

Inspectors wroteBased on observation, interview, and facility document review, the facility failed to maintain the essential equipment in safe operating condition. * The facility failed to ensure the hot water booster for the dishwasher was working to maintain the acceptable hot water for the dishwasher to function properly. This failure had the potential for the equipment to not function in the way it was intended, which could cause food borne illnesses for the residents.