Miller Nursing Home

F-F146 complained that the CNAs were wiping Resident R146 with a wash rag and not using wipes,

the wash rags were too rough and irritated her peri area. RN CCC1 revealed the results of grievances were reported back to the complainant verbally; nothing was provided in writing.

During an interview on 2/6/2025 at 3:06 pm with the Director of Nursing (DON) revealed the results were reported to the individual who made the complaint orally. The DON stated the complainant could have a copy of the written grievance if they asked for it.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 4 of 7 115039 Department of Health & Human Services Printed: 09/09/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 115039 B. Wing 02/07/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Miller Nursing Home 206 Grace St Colquitt, GA 39837

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food

in accordance with professional standards. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 15406

Residents Affected - Some Based on observations, staff interviews, record review, and review of the facility's policy titled, Dietary Procedure Manual, the facility failed to ensure dietary areas were maintained in a sanitary manner. Specifically, food and supplements were not labeled properly, frozen meats were exposed to air, chemicals were stored with food, handwashing could not be completed without contamination of one's hands, floors were observed with built up substance, and the facility failed to use a sanitizer on kitchen surfaces. The deficient practice had the potential for transmission of food borne illness, and potential to affect 60 of 153 residents who received an oral diet served from the kitchen. (105 residents received partial to total nutrition needs via feeding tubes).

Findings include:

Review of the facility's policy titled, Dietary Procedure Manual, review date [DATE REDACTED], under Infection Control-Food Preparation revealed, B. Patient Service: 5. All foods stored in diet kitchen refrigerator should be covered and labeled, dated or in pre-packaged containers . 6. Covered food should be discarded after 72-hours if not consumed . Food Storage: 1. All foods in the refrigerators are covered, labeled, and dated if not in original container . 6. Proper storage techniques including containers, temperatures, coverings, and length of time should be known and practiced by all . Food Storage: 19. Cleaning supplies are stored separately from food supplies . Cleaning: 4. Equipment and work surfaces are cleaned and sanitized before and after each use . 5. Floors are swept and mopped daily . 8. The counters in serving and preparation areas are cleaned with germicidal solution at each workstation after each use . Perishable Food Item Storage-Procedure: Leftover food items are stored in covered containers. Each container is labeled as to the contents and dated.

1. Observation and interview on [DATE REDACTED] at 10:00 during the initial tour of the dietary department with the Food Service Supervisor (FSS), he revealed the main kitchen was in the process of being remodeled so the food service operation was spread out in several locations. Dietary staff were preparing meals in the physical therapy (PT) kitchen located a couple blocks away. There was a semi-truck freezer located next to the PT kitchen where frozen food was stored. The walk-in refrigerator located in the main kitchen in the hospital was still in use. There was also a makeshift kitchen set up in the facility with a steam table for tray line meal service, refrigerator/freezers and storage area. The following concerns were noted during the initial tour on [DATE REDACTED] from 10:00 am to 11:02 am:

a. Observation and interview with the FSS of the walk-in freezer truck revealed there were two boxes of meat, one bacon and one of pork chops that were not closed. The boxes had been opened and the plastic bag within the box had not been sealed exposing the entire top contents of the meat in the boxes to air. The FSS verified the meat was exposed to air and stated it should be completely covered/sealed.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 5 of 7 115039 Department of Health & Human Services Printed: 09/09/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 115039 B. Wing 02/07/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Miller Nursing Home 206 Grace St Colquitt, GA 39837

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 b. Observation and interview in the PT kitchen revealed a small storage room that contained food items such as canned and boxed of food. There were 4 gallons of bleach stored in the room with the food. The FSS Level of Harm - Minimal harm or verified the bleach should not be stored with food. The only garbage can in the PT kitchen was a 55 gallon potential for actual harm can with a lid on it which required touching the potentially soiled garbage can lid with clean hands, which was verified by the FSS. The FSS stated they had a foot operated can in the old kitchen which prevented staff Residents Affected - Some from soiling their hands, but it had not made it over to this temporary kitchen. Also, in the PT kitchenwas a bag of opened and thawed chicken tenders in the refrigerator that was unlabeled and undated. The manufacturer's expiration date was [DATE REDACTED]. The FSS revealed their system for labeling and dating was to go by the manufacturer's expiration date, and leftovers they would keep for no more than three days. The FSS verified the manufacturer's date on the chicken showed the food was expired, and revealed dietary staff were supposed to label foods with the name of the food and the date the food expired. There was a container of leftover chili dated [DATE REDACTED]; the FSS verified it was more than three days old. There were two packages of turkey lunch meat (per the FSS) in the reach-in refrigerator, one package opened and the other one not. Neither were labeled with the food item or date.

c. Observation and interview in the walk-in refrigerator in the hospital revealed there was black grime on the floor along the edge of the wall and floor and accumulated brown crusty debris in the corner. There was a box half full of individually packaged four ounce [brand name] nutritional shakes in the manufacturer's box which was dated [DATE REDACTED]. The FSS verified the shakes were past the expiration date. On each carton instructions read, use thawed product within 14 days. The FSS stated they used the manufacturer's expiration dates for the shakes, and she was not aware of the 14-day shelf life once the product was pulled from the freezer and placed in the walk in.

2. Observation and interview on [DATE REDACTED] from 10:35 am to 11:48 am with the Food Service Manager (FSM)

the following concerns were noted:

a. Station Five snack area refrigerator contained approximately 20 cartons of [brand name] nutritional shakes. There were no dates to indicate when the shakes had been pulled out of the freezer and thawed.

The FSM stated they received the [brand name] nutritional shakes frozen and pulled out what they needed and placed them in refrigeration. The FMS verified the label on the shakes indicated they should be used within 14 days of being thawed.

b. The walk-in refrigerator in the hospital kitchen was in the same condition noted on [DATE REDACTED]. There was black grime and brown crusty debris in the corners and along the walls. The FSM verified it needed to be cleaned.

c. The PT kitchen had a bag of unidentified small pieces of meat dated [DATE REDACTED]. The FSM verified it was a bag of bacon bits, it should be labeled with the food item and date, and it should be disposed of. The FSM stated their policy was to keep leftover food no more than three days, otherwise, they went by the expiration date on the box. The FSM stated staff should label foods with the date it was placed in refrigeration and the date it should be used by.

During an interview, the FSM was asked what sanitizer they used for kitchen surfaces. The FSM showed the surveyor a spray bottle of the product [brand name of product]. The FSM stated that it was the product they used to clean the tray line and kitchen surfaces.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 6 of 7 115039 Department of Health & Human Services Printed: 09/09/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 115039 B. Wing 02/07/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Miller Nursing Home 206 Grace St Colquitt, GA 39837

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Review of the label of the product and the Manufacturer's Safety Data Sheet for the product [brand named product] provided by facility revealed the product was a cleaning product and not a sanitizer. Ingredients Level of Harm - Minimal harm or included sodium dodecylbenzene sulfonate, sodium poly (oxyethylene) dodecyl ether sulfate, and organic potential for actual harm sulfonic acid salt.

Residents Affected - Some

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 7 of 7 115039