Bibb Medical Center Nursing Home

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, the Resident Council Meeting on 11/29/2023, a test tray on 11/29/2023, and a facility policy titled, Food Service, the facility failed to ensure food was served warm, palatable and enjoyable. This had the potential to affect 114 of 114 residents receiving meals from the kitchen. Findings include: The facility's undated policy, Food Service documented: . PROCEDURES: . 4. A conscientious effort is made to make the food, trays, and service as attractive as possible. Resident Identifier (RI) #22 was admitted to the facility on [DATE]. During tour of the facility on 11/27/2023 at 12:06 PM, RI #22 stated, most of the time food was cold, especially breakfast. RI #27 was admitted to the facility on [DATE]. On 11/28/2023 at 5:15 PM RI #27 was eating dinner in his/her room. When asked about the food, RI #27 said, the food was cold but he/she was going to eat it because of being hungry. RI #27 said, the food was served cold frequently. During the Resident Council Meeting, held on…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, interviews, the facility policy Proper Labeling of Food items , and the 2022 Food Code from the United State (U.S.) Food and Drug Administration (FDA); the facility failed to ensure: 1) food stored in the freezer was covered and sealed properly, outdated food was discarded and; 2) the temperature of blended (puree) foods was measured before serving to residents. This had the potential to affect 114 of 114 resident receiving food from kitchen. Findings Include: 1. The 2022 U.S. FDA Food Code included the following: 3-305.11 Food Storage. (A) . FOOD shall be protected from contamination by storing the FOOD: . (2) Where it is not exposed to splash, dust, or other contamination . On 11/27/2023 at 10:45 AM, during the initial kitchen tour an observation was made of food stored in the freezer. Salisbury steak was exposed to the air in an unsealed aluminum container. The lid to the container was not sealed properly and there was ice observed on the meat. The freezer contained roast beef in a plastic eight-quart container with use by 11/26/2023 date and four-quart…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, interviews, and review of a facility policy titled Hand Hygiene, Laundry/Linen Distribution, and Handling Clean Linen the facility failed to ensure: 1) staff performed hand hygiene when a Certified Nursing Assistant (CNA) delivered meal trays, picked an item off the floor, and touched a resident's food, when a Laundry Aid (LA) delivered clean linen to eight different resident's rooms on the 200 hall, and before a Laundry Assistant (LAS) handled clean linen; 2) a LAS did not hold clean linens against her personal clothing; and 3) clean linen was covered while being transported on the 200 hall. These failure had the potential to affect Resident Identifier (RI) #53, RI #25, residents on the 200 hall, and all residents in the facility who received linen from the laundry room. Findings include: The facility policy with an effective date of 02/2001 and a review/revision date of 05/2021 titled Hand Hygiene revealed . POLICY: All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. This…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, resident record review, and review of the facility policy Promoting/Maintaining Resident Dignity During Mealtimes, the facility failed to ensure Resident Identifier (RI) #38's lunch meal was not served on Styrofoam on 11/27/2023 and the staff delivering laundry gained permission to enter residents' rooms before entering on 11/27/2023. This had the potential to affect RI #38, one of 10 sampled residents observed at mealtime and residents residing on the 200 hall. Findings include: On 11/27/2023 at 12:53 PM, Laundry Aide (LA) #18 was observed delivering resident's clothing to room numbers 213, 211, 210, 208, 207, 204, 203, and 202, entering each room without knocking, announcing herself, or waiting for permission before entering. On 11/28/2023 at 8:40 AM during an interview with LA #18, she said, she should knock or ask to enter a resident room before going in. When the laundry aide was asked if she knocked on residents' doors before entering, she said, she did not. When asked…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, resident record reviews, and review of the Centers for Medicare & (and) Medicaid Services Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual Version 1.18.11, the facility failed to ensure Resident Identifier (RI) #64's annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/15/2023 was accurately coded for weight loss or gain and RI #114's quarterly MDS assessment with an ARD of 10/24/2023 was accurately coded to reflect RI #114 did not receive an anticoagulant medication during the assessment period. This had the potential to affect two of 29 sampled residents whose MDS assessments were reviewed. Findings include: The Long-Term Care Facility Resident Assessment Instrument User's Manual documented: . Steps for Assessment for K0200B, Weight 1. Base weight on the most recent measure in the last 30 days. K0300: Weight Loss . Code 2, yes, .: if the resident has experienced a weight loss of 5% or more in the past 30 days or 10% or more in the last 180…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview, document review and a facility policy titled, Continuing Education, the facility failed to ensure 27 CNA's (Certified Nursing Assistants) had the required 12 hours of CEUs ( Continuing Education Units) training per year. This deficient practice affected 27 out 29 CNA's whose training records were reviewed. Findings Include: A review of a facility policy titled, Continuing Education, with an review/revision dated of 6/2001 documented: PURPOSE: To maintain sufficient continuing competence of Nurses Aides. POLICY: All Nurses Aides will be offered twelve (12) hours of continuing education per year .PROCEDURE: .3. Each must receive .twelve(12) hours .training per year . On 8/22/19 at 11:00 a.m, the Surveyor reviewed the CEU's training records for the CNA's employed by the facility from the last twelve months between their hire date (month/date). There was no documentation of the required 12 hours of CEU's, during a twelve month span, for 27 CNAs. On 8/22/18 at 11:23 a.m., an interview was conducted with EI (Employee Identifier) #1, DON (Director of Nurses). EI #1 was…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, interviews and a review of facility policies titled, Steamtable temperatures, Cleaning of food carts, and Handwashing Guidelines-Dietary Employees, the facility failed to ensure: 1) the temperatures were taken of all foods on the tray line; 2) food carts used to transport residents meals were not dirty and; 3) staff washed their hands when entering the kitchen. This had the potential to affect 113 of 113 residents who received meals from the kitchen. Findings Include: 1) Review of a facility policy titled, Steamtable temperatures, with no date revealed: .POLICY: All steamtable temperature will be checked and documented prior to food service. PROCEDURES: 1. All foods held on the steamtable will be checked and all temperature will be documented by the assigned dietary personnel prior to service. On 7/11/18 at 11:54 rice was brought to the steam table by (Employee Identifier) EI #4. Dietetic Assistant. EI #4 did not take the temperature of the rice, nor did EI #1, the Cook. On 7/11/2018 at 2:46 p.m., the surveyor conducted an interview with EI #1, the Productive…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.