Cordele Health and Rehabilitation

Inspectors wroteBased on observations, staff interviews, and review of the facility policy, Pureed Diet Preparation and Services, the facility failed to ensure pureed foods were prepared according to standardized recipes and professional food service standards for residents requiring texture-modified diets. This deficient practice had the potential to affect seven residents who received pureed diets and could increase the risk that residents would receive food with an inconsistent texture that did not meet their prescribed dietary needs. Findings Include:Review of the facility policy titled, Pureed Diet Preparation and services, documented under the section, Standardized Recipe Requirements section, all pureed diet items shall: Be based on standardized, dietitian- approved recipes. Include ingredient lists, preparation instructions, and yield information. [...]

Inspectors wroteBased on observations, staff interviews, and review of the facility policy titled Safe Food Handling, the facility failed to ensure food was properly labeled, dated, and maintained in sanitary conditions to prevent foodborne illness. This deficient practice had the potential to affect 61 residents.

Inspectors wroteBased on observations, staff interviews, record review and review of the facility's policy titled Dignity Policy for Long-Term Care, the facility failed to respect the dignity of one of 32 sampled residents (R) R1. This deficient practice had the potential to cause loss of self-worth and diminished quality of life.

Inspectors wroteBased on observations, resident and staff interviews, record review and review of the facility policy titled, Resident Call Light Response Policy, the facility failed to provide reasonable accommodation of needs by not placing call lights within reach of two of 32 sampled residents (R) R18 and R39. This deficient practice had the potential to cause delayed assistance, potential for falls and unmet needs.

Inspectors wroteBased on record review and staff interviews the facility failed to ensure that a discharge Minimum Data Set (MDS) assessment was transmitted within 14 days of discharge to the Centers for Medicare and Medicaid Services (CMS) System for one of four resident (R) R22 reviewed for resident assessments.

Inspectors wroteBased on observations, staff and family interviews, record review, and review of the facility policy titled, LTC MDS and Care plan, the facility failed to develop a comprehensive, person-centered care plan for one of 33 sampled residents (R) (R47). This deficient practice had the potential to place R47 at risk of unmet needs, medical complications, and a diminished quality of life.

Inspectors wroteBased on observations, staff interviews and review of the facility's policy titled, Accident Hazards at Bedside Policy (Long- Term Care), the facility failed to ensure the environment was free of accident hazards by having one pair of scissors on one of four medication carts unattended. This deficient practice had the potential to cause severe injury to the residents.

Inspectors wroteBased on observations, resident and staff interviews, record review, and review of the facility policy titled, LTC Oxygen, the facility failed to maintain respiratory equipment consistent with professional standards for one of two sampled residents (R) (R47). Specifically, the facility failed to bag a continuous positive airway pressure(CPAP) mask when not in use. The deficient practice had the potential to cause infection.

Inspectors wroteBased on observations, staff interviews, record review, and review of the facility policies titled, Cleaning Glucometer and Disinfecting, Medication Administration, F/C care/Peri-care, Infection Control - Standard and Transmission-based Precautions and Infection Control Hand Hygiene, the facility failed to implement infection control practices. Specifically, staff were observed touching a tablet with bare hands during resident care, failing to disinfect a glucometer between resident use, and failing to sanitize bedside tables after catheter care for two of 32 sampled residents (R) R50, R87. This deficient practice had the potential to increase the risk of infection and adversely affect residents' health and safety.

Inspectors wroteBased on observations, staff interviews, and review of the facility policy titled, Dietary Cleaning, the facility failed to ensure that the walk-in refrigerator, the oven, and the fryer were kept clean and sanitary, in a manner that prevents foodborne illness to the residents. This deficient practice had the potential to affect 56 of 62 residents who receive food from the kitchen.

Inspectors wroteBased on observations and staff interviews, the facility failed to maintain a clean, sanitary, and comfortable environment for three of 13 resident rooms (room [ROOM NUMBER], room [ROOM NUMBER], and room [ROOM NUMBER]) reviewed. Specifically, the PTAC (Packaged Terminal Air Conditioner) vents were dirty. This deficient practice had the potential to compromise the health and safety of residents and staff by increasing the risk of respiratory and allergy symptoms due to inadequate air filtration and reduced fresh air circulation.

Inspectors wroteBased on staff interviews, record review, and review of the facility policy titled, (Long Term Care [NAME] Data Set) LTC MDS and Care Plan, the facility failed to follow the care plan for one of eight residents (R) (R168) and failed to include a care plan for O2 use with interventions for one of eight R (R37) who receive (O2) therapy. The deficient practice had the potential for R168 and R37's oxygen needs to go unmet.

Inspectors wroteBased on observations, staff interviews, record review, and review of the facility policy titled, Medical Gas Cylinder Storage, the facility failed to ensure an oxygen (O2) tank was properly secured for one of five residents (R) (R37) reviewed for O2 storage. The deficient practice had the potential to result in harm or injury to the facility's residents.

Inspectors wroteBased on observations, resident and staff interviews, record review, and review of the facility's policies titled, Oxygen (O2) Concentrator and LTC (long term care)-Oxygen, the facility failed to ensure that residents received O2 as ordered for two of eight residents (R) (R29 and R168) receiving O2 therapy; and failed to ensure that the O2 concentrator (machine that supplies O2) was clean, sanitary, and free of sediment build-up for one of eight R (R33) receiving O2 therapy. The deficient practice had the potential to put the residents at risk for medical complications such as hypoxia, respiratory depression, and infection.

Inspectors wroteBased on observations, staff interviews, and review of the facility's policy titled, Hand Hygiene and Policy Procedure, the facility failed to ensure the infection control process was followed for two residents (R) (R48 and R168) during medication observation. The deficient practice had the potential to spread infection to other residents, staff and visitors.

Inspectors wroteBased on resident and staff interviews, record review, and review of the facility's policies titled, Non-Pressure Ulcers, and Treatment Administration Record (TAR), the facility failed to ensure that wound care was provided as ordered by the physician, for one of three residents (R) (RA) with venous ulcers. The deficit practice caused RA not to receive medical treatments as needed, and placed RA at risk for adverse consequences.

Inspectors wroteBased on observations, record review and staff interviews, the facility failed to follow physician orders for one of eight residents (R) #49. Specifically, the facility failed to ensure intravenous (IV) access site was removed from resident as ordered by physician after antibiotic regime was completed. The deficient practice had the potential to increase the probability of infection to occur at the IV insertion site.

Inspectors wroteBased on observations, record review, and staff interviews the facility failed to ensure that oxygen (02) tubing and respiratory equipment were properly stored for two (2) of 15 residents (R) R#32 and R#35. Specifically, the facility failed to ensure that the 02 tubing for R#32 was changed weekly as ordered, the facility also failed to ensure R#35 C-PAP (Continuous Positive Airway Pressure) (ventilation in which a constant level of pressure is continuously applied to the upper respiratory tract of a person) mask was properly stored when not in use.

Inspectors wroteBased on observation and staff interviews. The facility failed to ensure the kitchen was maintained in a clean and sanitary condition. The deficient practice had the potential to affect 58 of 62 residents receiving an oral diet.

Inspectors wroteBased on observation, record review, and review of the facility policies titled, LTC-Pressure Ulcers and Hand Hygiene. The facility failed to ensure that proper hand hygiene was conducted during wound care treatment for one of 10 residents (R#31). The deficient practice had the potential to increase the probability of infection risks for the resident.