Bostick Nursing Center

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Based on observations, staff interviews, and review of the facility policies titled Equipment and Warewashing, the facility failed to ensure that dishware was not stored wet. In addition, the facility failed to ensure sanitary conditions in the kitchen. These deficient practices had the potential to place the 213 residents receiving nutrition and hydration from the kitchen at risk of a foodborne illness. Findings include:

Review of the facility's policy titled Equipment, revised 9/2017, revealed the Policy Statement section included, All foodservice equipment will be clean, sanitary, and in proper working order.Review of the facility's policy titled Warewashing, revised 12/2024, revealed the Procedures section included, . 4. All dishware will be air dried and properly stored.During a tour of the kitchen on 9/22/2025 at 9:50 am with the Certified Dietary Manager (CDM), observation revealed that washed plates stacked in the plate storage had water between them. Continued observation revealed that a fan mounted on the wall, and directed toward

the clean section of the kitchen, had a buildup of gray and black debris. Further observation revealed the ceiling vent over the exit side of the dishwasher had a buildup of grey material. In an interview on 9/22/2025 at 10:25 am, Dietary Aide (DA) FF confirmed that her duties include drying and storing dishware and utensils, and using the high-temperature dishwasher. DA FF confirmed that the plates had water on them in

the storage rack. She stated she should leave them on racks to dry, and was uncertain as to why she did not.In an interview on 9/22/2025, at 10:44 am, the Maintenance Director confirmed he was responsible for cleaning the fan and vent in the dishwashing area. The Maintenance Director explained that he planned to clean the vents every six months across the building, although he did not maintain any logs or documentation. He stated that the fan was cleaned as necessary.

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date

these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE

TITLE

(X6) DATE

FORM CMS-2567 (02/99) Previous Versions Obsolete

Facility ID:

If continuation sheet

Event ID:

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/18/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Bostick Nursing Center

1700 Bostick Circle Milledgeville, GA 31061

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 0925

Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.

Level of Harm - Minimal harm or potential for actual harm

Based on observations, staff interviews, and review of the facility's pest control contract and service records, the facility failed to maintain effective pest control in the kitchen. This facility practice had the potential to place the 213 residents who received nutrition and hydration from the kitchen. Findings include:Observation on 9/22/2025 at 10:07 am revealed flies in the kitchen, with one fly landing on a four-ounce (oz) serving bowl with pudding. Observation on 9/22/2025 at 10:16 am revealed flies in the kitchen, hovering around the steam table, and two landing on the pole that supports the table.Observation

on 9/23/2025 at 12:30 pm, during lunch meal pass, revealed flies hovering around the steam table and prepared food, with one fly landing on a four-oz serving bowl of assorted fruits. In an interview on 9/22/2025 at 10:10 am, the Certified Dietary Manager confirmed the presence of the flies in the kitchen area. In an

interview on 9/24/2025 at 11:03 am, the Maintenance Director stated that the prolonged summer resulted in

the continued presence of flies, and he had not thought to put out fly bait. Review of the Pest Control contract revealed that services began with the facility on 5/26/2020 and included one service per month.

The contract stated pests to be managed by this service program included German roaches, ants, American roaches, mice/rats, silverfish, fire ants, Oriental roaches, and Smoky brown banded cockroaches.

Review of the Pest Control monthly appointment record from January 2025 to August 2025 revealed there were no targeted services identified for flies.

Residents Affected - Many

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet