Tabor Hills Health Care Fac

In the surveyor’s words

From the most serious findings on record at Tabor Hills Health Care Fac, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF812May 9, 2024

  Based on observation, interview, and record review the facility failed to ensure the hot water dish machine reached 160 degrees Fahrenheit rinse temperature, failed to ensure staff changed gloves between handling soiled and clean dishes and failed to ensure the dry storage area did not contain expired canned food products. This applies to all 63 residents who receive oral diets from the kitchen. The findings include: On [DATE], at 10:11 AM, V6 (Dietary Aide) was washing dishes using the hot water dish machine. V3 (Maintenance Director) and V4 (Dining Room Supervisor) were present and were asked to validate the dish machine temperature, V3 placed the disc thermometer in the dish rack. V3 then placed the rack on the conveyor and ran it through the dish machine. […]

• No harm, potential for more than minimal, widespreadF812Jun 16, 2023

  Based on observation, interview, and record review, the facility failed to store food items in sanitary conditions by having unlabeled and undated food items in dry storage and in a walk-in cooler, and ice buildup on food items and the ceiling in the freezer. This affects all 70 residents consuming food from the kitchen. Findings include: On 6/14/23 at 10:10 AM, V2 (Director of Nursing - DON) stated, We have 70 residents on the certified side. Two are on gastrostomy tube (GT) feeding, but they are also on pleasure feeding. So, all 70 residents are eating from the kitchen. On 6/16/23 at 9:40 AM, during the initial kitchen tour with V5 (Assistant Dietary Manager), the dry kitchen storage was observed with a partially used five-pound Graham Cracker Crumbs with no label or date. […]

• No harm, potential for more than minimal, widespreadF812Aug 24, 2022

  Based on observation, interview, and record review the facility failed to ensure the kitchen food storage was free of pests which applies to all 81 residents reviewed for sanitary food storage. The findings include: The CMS-672 dated 8/22/22 showed a census of 81 residents. On 8/22/22 at 10:00 AM, upon entering the kitchen's dry storage area, a swarm of flying insects were concentrated on and around the bread and bread cart in the middle of the storage room. Across the storage room there was a smaller swarm of flying insects centralized around bananas stored on a shelf. On 8/22/22 at 10:15 AM, V17 Dietary Manager and V20 Maintenance/Housekeeping Manager (while on kitchen tour) stated the facility has had problems with drain flies for about 2 months. […]

• No harm, potential for more than minimal, patternF883May 9, 2024

  Based on interview, and record review, the facility failed to administer the pneumococcal vaccine to residents according to the CDC (Centers for Disease Control and Prevention). This applies to 4 of 5 residents (R8, R13, R17, and R56) in the sample of 19. The findings include: On May 7, 2024, at 1:22 PM, V7 (Infection Preventionist Nurse) said the facility follows CDC recommendations for pneumococcal vaccine timing. 1. R8's EMR (Electronic Medical Record) showed R8 was a [AGE] year-old resident, admitted to the facility on [DATE], with multiple diagnoses including hypertension, pneumonia, and anemia. R8's Immunization Record showed R8 received the PCV13 (13-valent pneumococcal conjugate vaccine) on March 15, 2022. […]

• No harm, potential for more than minimal, patternF880Jun 16, 2023

  Based on observation, interview, and record review, the facility failed to implement infection control measures to prevent cross-contamination from soiled linens, soiled gloves, incontinence wipes, and resident trays. This applies to 11 of 23 residents (R4, R12, R17, R28, R42, R49, R52, R56, R60, R68, and R278) reviewed for infection control. Findings include: 1. On June 13, 2023, at 11:26 am, V7 CNA (Certified Nursing Assistant) placed a disposable incontinence brief and pants on R278 while R278 was in a standing position, V7 threw R278's soiled under pad onto the floor. R278 was assisted to her wheelchair. While still wearing soiled gloves, V7 walked out of R278's bedroom to the clean linen cart in the hallway. […]