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Based on observation, staff interview, policy/procedure review, and review of the manufacturer guidelines, the facility failed to clean/maintain in safe operating condition two (2) hydrocollators, one (1) paraffin heat therapy unit, one (1) bottle warmer, and one (1) upright freezer according to the manufacturer guidelines on five (5) of eight (8) therapy patient care equipment.

Findings Include:

Observation of the two (2) Hydrocollator Master Heating Units, one (1) Paraffin Heat Therapy unit, and one (1) Bottle Warmer unit of Hospital #1's "Temperature Log" for equipment in the clean equipment column, revealed units were not cleaned every two (2) weeks.

Observation of the one (1) Upright Freezer Model #HUM013EA on Hospital #1's "Temperature Log" for equipment in the clean equipment column, revealed the unit was not cleaned twice a year.

An interview with Therapist #1 at 3:15 p.m. on 09/09/2025 confirmed there is no documentation the equipment was cleaned since 09/25/2024. Therapist #1 reported the equipment was cleaned approximately five (5) weeks ago however this is no documented evidence the equipment was cleaned.

An interview with the Administrator at 12:29 p.m. on 09/11/2025 confirmed the facility does not have a policy and procedure for cleaning the bottle warmer, the facility follows the manufacturer's guidelines.

Review of the "Temperature Log" for equipment revealed facility last documented cleaning for the two (2) hydrocollators, one (1) paraffin heat therapy unit, one (1) bottle warmer, and one (1) upright freezer was on 09/25/2024.

Review of hydrocollator "Master Heating Units Operation Manual" copyright 2000 revealed, " ...the tank should also be drained and cleaned systematically, at a minimum every two (2) weeks ...".

Review of Hospital #1's "Hydrocollator and Heating Pad Policy and Procedure," reviewed 08/15/2022 revealed, " ...the hydrocollator machine should be cleansed per manufacturer's guidelines regarding frequency and method ...it is the recommendation ...this process occurs at least every two (2) weeks ...".

Review of the "Paraffin Heat Therapy Owner's Guide," not dated revealed, " ...the Paraffin Unit should be cleaned when significant discoloration or yellowing of the paraffin is noticed or when excessive sediment is observed in the tank ...".

Review of Hospital #1's "Paraffin Bath Treatment Policy and Procedure," reviewed 05/22/2025 revealed, " ...the Paraffin Bath machine should be cleansed per manufacturer's guidelines regarding the frequency and method ...it is the recommendation ...this process occurs at least every two (2) to three (3) months ...".

Review of "Bottle Warmer Operating Instructions," not dated, revealed on page seven (7) of 14, " ...routine cleaning (every two (2) weeks or as needed) ...wash inside and outside with a sponge, cloth or cleaning pad using a mild soap solution ...".

Review of "Upright Freezer User Manual," Model #HUM013EA, revealed " ...clean the inside ...at least twice a year ...".
Review of facility's "Freezer/Cold Packs Policy and Procedure," reviewed 08/15/2022 revealed " ...should be cleansed per manufacturer's guidelines ...".

During the exit conference on 09/11/2025 at 1:00 p.m. survey findings were discussed, and no further documentation was submitted for review.