Galleria Woods Skilled Nursing Facility

Inspectors wroteBased on observations, interviews, and review of the facility policy titled, Labeling and Dating for Safe Storage of Food, the facility failed to ensure food items in the dry storage area were sealed and labeled with an open date and used-by date. This deficient practice had the potential to affect 28 out of 28 residents receiving meals from the kitchen. Findings Include: A review of a facility policy titled, Labeling and Dating for Safe Storage of Food, with a revised date of 3/6/20, revealed, OBJECTIVE: . labeling and dating are critical in order to promote food safety. All products should be dated when opened. Use-By dates on all food once opened . On 12/14/21 at 8:15 AM, the surveyor toured the kitchen. [...]

Inspectors wroteBased on observations, interviews, and review of a facility policy titled, Crisis Use of Facemasks (COVID-19 Outbreak), the facility failed to ensure staff were correctly wearing their face masks while in the facility. This deficient practice had the potential to affect all 28 of 28 residents residing in the facility and interacting with facility staff. Findings Include: A review of a facility policy titled, Personal Protective Equipment-Contingency and Crisis Use of Facemasks (COVID-19 Outbreak), dated April 2020, revealed, . Objective To prevent transmission of infectious agents through the inhalation of droplets. General Procedure for Donning and Doffing Masks 1. To put on mask: . b. Be sure that the face mask covers the nose and mouth while wearing. e. Do not remove the mask while performing treatment or services for a resident. [...]

Inspectors wroteBased on observations, interviews, medical record review and review of a facility policy titled, Care Plans-Comprehensive, the facility failed to ensure RI (Resident Identifier) #24's intervention for a fall mat at bedside was implemented on 12/15/21. This deficient practice affected RI #24, one of 13 residents whose care plans were reviewed. Findings Include: A review of a facility policy titled, Care Plans-Comprehensive, reviewed/revised May 2018, revealed: Policy Statement An individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs is developed for each resident. Policy Interpretation and Implementation .3. Each resident's comprehensive care plan is designed to: . e. Reflect treatment goals, .6. [...]

Inspectors wroteBased on observation, interview, and the Food and Drug Administration (FDA) 2017 Food Code, the facility failed to ensure the grease/oil receptacle was free from leaking oil. This was observed during the initial tour of the kitchen on 12/14/21, one of three days of the survey. This affected one of one grease/oil receptacle observed. Findings Include: A review of the FDA, 2017 Food Code, revealed: . 5-501.15 Outside Receptacles. (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 . On 12/14/2021 at 2:28 PM, the surveyor observed the dumpster area. The oil receptacle had oil draining from an open area in the bottom of the container. The oil leaves a trail about ten feet out from the oil container. [...]

Inspectors wroteBased on observations, interviews, and review of policies titled, POTS AND PANS- SANITIZING SOLUTION, CRITERIA FOR COMPLETION OF . QUARTERLY REPORT SANITATION FOR LONG TERM CARE and DISHWASHING PROCEDURE the facility failed to ensure: 1) wet pans were not stacked on top of each other; 2) staff did not use gloved hands to touch the broom, dust pan and then continue to wash dishes with the same gloves hands and 3) dietary staff had on a hair net while in the kitchen. This had the potential to affect 29 of 29 resident who received meals from the kitchen. Findings Include: 1) A review of a policy titled, POTS AND PANS-SANITIZING SOLUTION with a revised dated of 08/31/2018, revealed: .7. Sanitize pots and pans in third tank .8. Remove items. 9. Invert items on counter. Allow all items to air dry. On 4/10/2019 at 4:47 p.m. an observation was made of dishwashing of pans. [...]

Inspectors wroteBased on observation, interview, record review and review of a facility policy titled, Prevention of Catheter Associated Urinary Tract Infection, the facility failed to ensure Resident Identifier (RI) #19, a resident admitted to the facility with a Foley catheter, had a qualifying diagnosis for the catheter. This affected one of two residents sampled for Foley catheters. Findings Include: A review of a facility policy titled Prevention of Catheter Associated Urinary Tract Infection with an effective date of 1/2009 revealed: .Policy Detail A. Appropriate Urinary Catheter Use *Utilize urinary catheters when residents clinical condition demonstrates a need (see below for examples/guidance), and left in place only as long as needed. [...]

Inspectors wroteBased on observation, interview, record review and review of a facility policy titled, Storage and Expiration of Medications, Biologicals, Syringes and Needles, the facility failed to ensure 2 vials of Lorazepam (Ativan) and a 30 milliliter bottle of Lorazepam were in a secured locked box. This was observed on 4/10/19 and affected one of one medication rooms. Findings Include: A review of a facility policy titled, Storage and Expiration of Medications, Biologicals, Syringes and Needles with an effective date of 12/1/07 revealed: . Procedure: . 3. General Storage Procedures: 3.1 Facility should store Schedule II controlled substances . to be at risk for abuse or diversion in a separate compartment within the locked . 12 Controlled Substances Storage: [...]

Inspectors wroteBased on observations, interviews, a facility policy titled, PERSONAL HYGIENE, and a facility policy titled, Hair Restraints, the facility failed to ensure three kitchen staff restrained their hair during kitchen observations in the main kitchen and on the skilled unit while serving and/or preparing food. This was observed on two of three days of the survey and had the potential to affect all 26 residents receiving meals from the kitchen.

Inspectors wroteBased on observation, interview, resident record review, a Facility Policy titled Wound Observation and Pressure Injury/Ulcer Staging Policy and the National Pressure Ulcer Advisory Panel (NPUAP) Pressure Injury Stages, the facility failed to ensure RI (Resident Identifier) #10's right heel wound that contained slough was accurately staged on 4/23/18 and 4/30/18, when the wound was staged as a II (two); and accurately staged on 5/8/18 after the wound bed no longer contained slough and continued to be staged as a II. This affected one of two residents reviewed for pressure ulcers.

Inspectors wroteBased on record reviews, interviews and a facility policy titled, Discarding and Destroying Medication, the facility failed to ensure the method of destruction was documented on two of 12 months of medication destruction records. On 1/24/18 and 2/16/18 records did not reveal a method of destruction. This affected two of 12 months of medication disposal records reviewed.