Troy Health & Rehabilitation Center

Based on interview, document review, and the Rules of the Alabama State Board of Health, Alabama Department of Public Health (ADPH), Chapter 420-5-10, Nursing Facilities, original rules effective 8/23/1996 and last amendments effective 7/30/2016, the facility failed to ensure the full time Dietary Manager, Employee Identifier (EI) #1, met the definition of a Dietary Manager per the rules of the State of Alabama. This had the potential to affect 103 of 103 residents receiving meals from the facility kitchen. Findings Include: The Rules of the Alabama State Board of Health, ADPH, Chapter 420-5-10, Nursing Facilities, original rules effective 8/23/1996 and last amendments effective 7/30/2016 included the following: . 420-5-10-.01 Definitions. (1) Definitions - (a list of selected terms often used in connection with these rules): . (b) These Rules - Rules 420-5-10-.01 through 420-5-10-.11, Chapter 420-5-10, Nursing Facilities, Alabama Administrative Code. (l) Director of Food Services/Dietary Manager - . who is a full-time employee, and if not a qualified dietitian, is one who: (1) is a…

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 observation, interview, and the 2017 Food Code of the United States (U.S.) Public Health Service and U.S. Food and Drug Administration (FDA); the facility failed to: 1.) prevent the potential for cross-contamination from a) dishwashing machine and scrap sink drainpipes extending into the floor drain, thereby creating the possibility for backflow, b) the ceiling of the Walk-in Cooler having an accumulation of dust, c) a plastic mug buried in the flour bin, and; 2.) prevent the potential from contamination from vermin or insects by a) a sugar bin not securely covered, and b) providing potential harbor in the Chemical Storeroom by placing containers directly on the floor so that half of the small floor area could not be easily swept or mopped; 3.) prevent the potential for physical contamination from light tubes in a ceiling light fixture without a cover; 4.) maintain kitchen equipment in good repair as evidenced by a) a preparation table with folded damp cardboard under two legs to level it and 5.) prevent expired milk possibly being served to residents. This had the…

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 observation, interview, and the 2017 Food Code of the United States (U.S.) Public Health Service and U.S. Food and Drug Administration (FDA); the facility failed to ensure two of three dumpsters were not open and one of one oil refuse container was not covered in a thick layer of oil/grease, which could attract vermin. This had the potential to affect 108 of 108 residents in the facility. Findings Include: The 2017 Food Code of the U.S. Public Health Service and FDA included the following: . 5-501.15 Outside Receptacles. (A) Receptacles and waste handling units for REFUSE . used with materials containing FOOD residue and used outside the FOOD ESTABLISHMENT shall be designed and constructed to have tight-fitting lids, doors, or covers. (B) Receptacles and waste handling units for REFUSE . shall be installed so that accumulation of debris and insect and rodent attraction and harborage are minimized and effective cleaning is facilitated . 5-501.111 Areas, Enclosures, and Receptacles, Good Repair. . receptacles for REFUSE . shall be maintained in good repair. 5-501.113 Covering…

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 observation, interviews, record reviews and a review of facility policies titled Hand Hygiene Table, Hand Hygiene and LAUNDRY PROCESS, the facility failed to ensure: 1) Facility staff did not go room to room when picking up resident trays wearing the same gloves on 10/19/22; and 2) Linens were stored in a sanitary manner. This affected Resident Identifier (RI) #52 one of one residents observed during meals, and laundry had the potential to affect 108 of 108 residents residing in the facility. Findings include: 1. RI #52 was admitted to the facility on [DATE] and readmitted on [DATE]. A review of an undated facility policy titled Hand Hygiene revealed, . 2. Hand hygiene is indicated and will be performed under the conditions listed in, but not limited to, the attached hand hygiene table. A review of an undated facility policy titled Hand Hygiene Table, revealed . Between resident contacts . After handling contaminated objects . 1) On 10/19/22 at 5:25 PM an observation was made of Employee Identifier (EI)…

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 observation, interviews and review of a facility policy titled, Promoting/Maintaining Resident Dignity During Mealtimes, the facility failed to ensure Resident identifier (RI) #92 received their meal at the same time as their roommate, RI #76 and the facility further failed to ensure Employee Identifier (EI) #9, Certified Nursing Assistant (CNA) did not stand while feeding RI #92. This affected one of 24 sampled residents. Findings Include: The facility policy titled Promoting/Maintaining Resident Dignity During Mealtimes with no effective date documented: . 1. All staff members involved in providing feeding assistance to residents promote and maintain resident dignity during mealtimes. 5. All staff will be seated, if possible, while feeding a resident. RI #92 was admitted to the facility on [DATE] and readmitted on [DATE]. On 10/18/2022 at 12:25 PM, RI #76 was observed feeding self the lunch meal in the bed and RI #92 was observed without a meal. On 10/18/2022 at 12:29, RI #92 was asked if it bothered…

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 interview, record review and review of a facility policy titled B. Destruction of Medications, the facility failed to ensure the Non-Controlled Medication Destruction Sheets contained the two required signatures. This affected two of 12 months ([DATE] and [DATE]) of Non-Controlled Medication Destruction Sheets reviewed. Finding include: An undated facility policy titled B. Destruction of Medications, revealed the following: Policy: Expired, unusable, and discontinued medications must be destroyed in compliance with all state/federal laws and regulations. The facility is responsible for maintaining accurate records and appropriate witness signatures of destroyed medications. Procedure: . Non-controlled medication destruction must take place in the presence of two licensed nurses or one licensed nurse and a pharmacist. On [DATE] at 2:02 PM, the surveyor reviewed the Non-Controlled Medication Destruction Sheets for 10/2021, 11/2021, 12/2021, 01/2022, 02/2022, 03/2022, 04/2022, 05/2022, 06/2022, 07/2022,…

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's policies titled, Cleaning Dishes/Dish Machine and Buffet Style Dining, the facility failed to ensure: 1. utensils in bags were free of water and food like substance at the tray line; 2. plates were free of spots and 3. staff did not add old food to new food at the tray line. This had the potential to affect 142 of 142 residents who received meals from the kitchen. Findings Include: 1) A review of a facility policy titled, Cleaning Dishes/Dish Machine, with the year date 2013, revealed: Policy: All flatware, serving dishes, and cookware will be washed, rinsed, and sanitized after each use.Procedure: .11. Flatware should be pre-soaked prior to washing.Staff should assure that silverware is not nested prior to washing in cylinders. On 10/22/19 at 9:46 a.m., at the tray line the surveyor observed wet nesting of spoons, forks and knives in ready to go bags (plastic bags, seven) on a tray to be placed on the residents trays. The surveyor also observed most of all the bags with silverware in them were wet on the tray. There were…

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 observation, interviews and review of a facility document titled Perineal Care, the facility failed to ensure: 1. a Certified Nursing Assistant (CNA) did not place the wipes used for incontinent care for Resident Identifier (RI) #84 on the resident's bed, 2. the same CNA did not cover the clean wipes with the resident's bed covers, and 3. the CNA did not place the soiled wipe container on the inside of a clean brief before placing it on RI #84. This was observed on 10/23/19 and affected one of two residents observed for incontinent care. Findings Include: A review of an undated facility document titled Perineal Care revealed Purpose The purposes of this procedure are to provide cleanliness and comfort to the resident, to prevent infections and skin irritation, . Steps in the Procedure 1. Place the equipment on the bedside stand. Arrange the supplies so they can be easily reached. RI #84 was admitted to the facility on [DATE]. The resident's diagnoses included Anxiety Disorder and Dementia without…

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 observation, interview and review of facility policy Food Storage and the Food Drug Administration (FDA) 2017 Food Code, the facility failed to ensure: 1. an open bag of corn nuggets and an open bag of pork riblets were not in the freezer without a label and use by date; 2. a pork roast in a large zip lock freezer bag was not in the freezer with a use by date of 9/14/18, a bag of pork patties in the freezer with a use by date of 10/2/18 and a half gallon container of peaches was not in the refrigerator with a use by date of 10/20/18; 3. 2 bags of hot dog buns were sealed, 1 pack contained 6 buns, while the other contained 5 buns; 4. a metal pan in the refrigerator containing super pudding was labeled and dated, and 5. a dietary/cook's hair was completely contained in a hair net. This was observed on 10/22/18 and 10/23/18 and had the potential to effect 146 of 146 residents receiving meals from the kitchen. Findings Include: A review of a facility policy titled, Food Storage, date 2013, revealed: Policy: .Food is stored, .by methods designed to prevent contamination…

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 observation, interview, record review and review of a facility policy titled, Handwashing/Hand Hygiene, the facility failed to ensure a Certified Nursing Assistant (CNA) washed her hands between glove changes and did not use gloves she removed from her uniform pocket while performing incontinent care for Resident Identifier (RI) #126, a resident with a history of Urinary Tract Infection (UTI). This was observed on 10/23/18 and affected one of one residents observed for incontinent care. Findings Include: A review of an undated facility policy titled, Handwashing/Hand Hygiene, revealed . Policy Statement This facility considers hand hygiene the primary means to prevent the spread of infections.5. Employees must perform hand hygiene under the following conditions: . u. After removing gloves . 6. In most situations, the preferred method of hand hygiene is with alcohol-based hand rub. If hands are not visibly soiled, . for . the following situations: . b. Before donning sterile gloves; . 8. The use of…

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.