| 29 |
WINSTON COUNTY NURSING HOME |
255072 |
17560 EAST MAIN STREET |
LOUISVILLE |
MS |
39339 |
2019-06-06 |
812 |
F |
0 |
1 |
XJRB11 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, record review, and policy review, the facility failed to ensure that all staff who were responsible for food and nutrition service, could safely and effectively carry out these functions. This included consistent monitoring of all freezer temperatures; dating Mighty Shakes (nutritional shakes) with thawing date to indicate when to discard per manufacturer's recommendations; ensuring food to be served was at holding temperatures and reheated; documentation of food temperatures prior to serving meals; and ensuring that food is stored away from soiled surfaces. This deficient practice affected four (4) of six (6) resident cottages. Findings include: Review of the facility policy titled Food Storage and Labeling, which became effective on [DATE], revealed the procedures included the following: 1. All food items that are not in their original containers must be labeled and date marked to indicate use by date. 2. Suggested labeling includes: a. Common Name b. Date of preparation or use by date 3. Monitoring Storage Temperatures a. A thermometer is kept in storage areas. b. Temperatures in food storage units are monitored daily. c. Documentation of Temp is recorded on appropriate form. Review of the facility policy #B007 titled Food Handling Guidelines (HACCP), revealed the following procedures: - Hot Holding Temperatures - Foods should be held hot for service at a temperature of 140 F or higher. - Cold Holding Temperatures - Foods should be held cold for service at a temperature of 41 F or less. - Reheating - If a food is being held hot for service falls below 140 F, corrective action is taken and documented, as described on the Production Station Worksheet Report. - Internal temperature of potentially hazardous foods being held hot must be maintained at 135 F according to the 2013 FDA Food Code. The Company's standard for hot holding is 140 F. Review of the facility manual for hot food holding drop-in electric wells (model 500-HWI/D6) called Alto Shaam Halo Heat, revealed the following information was provided for operating instructions: - 2. Place pan dividers and empty pans in the wells. NOTICE: No matter what type of pan configuration chooses, pan separator bars or dividers must be used to close all gaps between pans and edges of the wells. If these gaps are not closed, heat will escape, heat distribution will be uneven, and uniform temperature will be very difficult to maintain. This is a VERY important requirement to follow whenever using this appliance is in use. 3. Preheat - a preheat set is built into the control. When knob is turned to desired setting the appliance will automatically preheat for a predetermined time and then begins to cycle on and off based on the setting selected. The pilot light (green) is on whenever the dial is turned to a number. 4. Load hot foods into the appliance - After preheating, place hot foods into the preheated pans located in the appliance or exchange pans with prefilled product pans. This appliance is designed for hot food holding. Only hot foods should be placed into the appliance. Potentially hazardous foods should be held in the appliance at setting 10. If lower settings are used, ensure the food has maintained safe food temperatures. Lower settings should be tested by user to ensure food has maintained safe food temperatures between 140 and 160 F. All pan divider bars required must be utilized at all times with the pan configuration chosen. Before loading food into the appliance, use a pocket-type thermometer to make certain all products have reached an internal temperature of 140 F to 180 F. Reset thermostat(s) as needed - After all products are loaded into the appliance, it is necessary to reset the thermostat(s). Since proper temperature range depends on the type of products and the quantities being held, it is necessary to periodically use a pocket thermometer to check each item to make certain the correct temperatures range is between a minimum of 140 and 180 F. Cypress Cottage Observation: Initial tour of the Cypress Cottage kitchen area, accompanied by Licensed Practical Nurse (LPN) #13 on [DATE] at approximately 10:05 AM, revealed the internal temperature of the French door refrigerator with ice maker was 40 degrees Fahrenheit (F). Further observation of the refrigerator revealed there was an eight (8) ounce carton of whole milk on the refrigerator door shelf which had been opened and not dated. A re-sealable storage plastic bag with pieces of watermelon was not labeled or dated. Five (5) 8-ounce cartons of fat free milk which expired on [DATE]. And no thaw date on three (3) regular and 11 no sugar added 4-ounce mighty shakes cartons good for 14 days after thawed. During further observation of the Cypress Cottage kitchen on [DATE] at approximately 10:12 AM, with the LPN #13, revealed a form entitled Refrigeration Temperature Record was noted attached to the side of the refrigerator which showed no monitoring of the freezer temperatures were being documented. Observation of lunch meal service in the Cypress Cottage kitchen on [DATE] at 11:34 AM, revealed the Alto Shamm five (5) pan drop in hot holding electric wells had all five (5) knobs at a setting of 7. During that observation it was noted all the wells were uncovered and on the last well on the right, staff had serving utensils including scoops and main entree plates. Continuation of the observation in the Cypress Cottage kitchen on [DATE] at 11:55 AM, revealed a contract Dietary Staff Worker (DSW) #14 arrived with the hot food to be served in an insulated box. All the foods were in different sized pans and covered with plastic. All the food pans were placed into the hot wells except for the one (1) that contained the plates and serving utensils and second one to the left. Small pans of the pureed and chopped meat were noted to be left on the back edge of the hot well near the wall with no access to any heating element. Since the pans were not big enough, they did not cover the entire wells leaving spaces in which the heat could escape. At approximately 11:58 AM, DSW #14 left the kitchen area and CNA #8 calibrated her digital thermometer to 33 F. Once she calibrated her thermometer she began to take the food temperatures. She first started with the pureed and chopped which were both noted to still be by the back edge of the hot holding heated electric wells. The temperature of the pureed chicken was noted to be 113.2 F and the ground chicken was 119.7 F at approximately 12:04 PM. CNA #8 was asked what the food temperature should be when reheated to which she reported it should reach 165 F when reheated. An interview with CNA #15 on [DATE] at approximately 10:10 AM, in the Cypress Cottage kitchen area by the refrigerator, revealed she was not aware that the manufacturer's instructions for the Mighty Shakes, which indicated they were to be used within 14 days of the item being thawed. CNA #15 indicated the Mighty Shakes came already thawed from the Dietary Department and placed in the refrigerator. Interview with CNA #8 on [DATE] at 11:52 AM, in the Cypress Cottage kitchen, revealed the only time she had received any training regarding the kitchen area responsibilities and use of equipment was upon hire during orientation, where she was able to shadow another CN[NAME] She indicated that a CNA would be allowed to shadow another CNA until they themselves told them they were comfortable to start working on their own. The CNA also stated that there were two (2) CNA shifts and each one is supposed to monitor the temperatures for the refrigerator and freezer in the kitchen and monitor for expired items in them. On [DATE] at 12:34 PM, CNA #8 was asked if the heated wells were supposed to have covers and she reported that as far as he knew they had never had any covers for the wells here in Cypress Cottage. CNA #8 stated that she usually kept knob settings at a setting of 7 to 9 for the food, area and in the well where the plates are stored, she had it set to five 5, because at a setting of 10, the plates would get too hot to touch. Per CNA #8, regarding who was responsible to clean the wells, she stated it was the responsibility of the Dietary Department. Interview on [DATE] at approximately at 9:16 AM, with DSW #10, revealed the Dietary staff delivered the food to the cottage kitchens and placed the food pans into the hot holding wells. The CNAs were responsible for serving the food and determining the setting of the temperature knobs for the hot holding electric wells. Interview with the Dietary Manager (DM) on [DATE] at 9:22 AM, revealed the food temperatures were taken prior to delivering the food delivered to the cottages. If they were out of temperature range, then they would heat the food until within an acceptable temperature range. The food was then delivered to each cottage in insulated hot boxes called Cambros. She reported that prior to all this happening, the CNAs were supposed make sure to turn on the hot holding electric wells in the morning to high so that when the food was brought it would stay hot, and at least 30 minutes prior to serving they should lower the temperature to half the setting. The DM stated that the wells were also supposed to have lids, but she just found out yesterday that only one (1) cottage had lids to be used for the hot holding electric wells. The DM also stated the staff was supposed to report to her if they needed any equipment for the wells, so she could order items needed such as the lids. DM further stated the responsibility fell upon the nurse to educate the CNAs on the kitchen tasks. The DM was not sure who trained the nurses on the kitchen tasks. She reported she only provided them with forms for them to use such as temperature logs for refrigerators, food serving temperature logs, etc. The DM further stated that a case of Mighty Shakes was thawed prior to delivery to the cottages, but no date was written on the shakes to identify when they were thawed once they were delivered to the cottages and placed in the refrigerators. Once the items were delivered to the cottages the CNAs were responsible for placing them and all other items delivered to them in the appropriate refrigeration unit. Interview with Nursing Home Administrator (NHA) on [DATE] at approximately 9:43 AM, revealed upon hire during orientation, all CNAs were trained on what was to be done in the kitchen at the cottages by lead educator CNA #7. She indicated the lead educator CNA was Servsafe approved. This meant the lead educator CNA had been trained and certified on food and beverage safety. Elm Cottage - Observations: Observation of the Elm Cottage kitchen on [DATE] at approximately 10:49 AM, with LPN #13, revealed CNA #9 was present. During the observation the French door refrigerator with ice maker was noted to have an internal temperature of 38 degrees F. When the refrigerator was opened it contained four (4) regular and two (2) no sugar added vanilla Mighty Shakes on the top shelf with no thawing date identified. An interview with the CNA #9 during that observation revealed she was not sure how long the Mighty Shakes had been thawed out. Further observation of the French door refrigerator revealed the freezer contained two (2) large re-sealable bags containing two (2) 4-ounce orange sherbet foam cups and ten (10) 4-ounce vanilla ice cream foam cups, frozen to touch, but no thermometer was observed inside to monitor the internal temperature of the freezer. Observation on [DATE] at 11:21 AM, of the Elm Cottage kitchen, revealed the drop in hot holding electric wells currently had a pan of rolls covered with plastic in one well and in the last well towards the right were the plates and serving utensils. Observation of the Elm Cottage kitchen on [DATE] at approximately 11:51 AM, revealed DSW#14 brought the food in the insulated box and placed items in the drop in hot holding electric wells leaving multiple spaces which would let the heat escape. At approximately 11:58 AM, the two (2) CNAs (CNA #11 and CNA #12) in Elm Cottage were observed placing multiple sized pans on the countertop containing the following: 1) salad made with lettuce, cherry tomatoes, and shredded cheddar cheese; 2) ranch dressing; 3) chocolate mousse; 4) angel food cake with a side of strawberry sauce. CNA #11 was observed taking the temperatures of the cold items on the counter at approximately 12:11 PM, which were as follows: - salad - 60.9 F - salad dressing - 63.2 F - chocolate mousse - 49.1 F - angel food cake - 54.7 F When CNA #11 was asked what she would do, she responded she would place the items back in the refrigerator and let dietary know. She did not place the items in the refrigerator at the time. Observation of the temperature for the hot food items on the hot holding heating electric wells prior to the lunch meal service by CNA #11 at 12:16 PM, revealed the following: - mechanical soft meat - 127 F - pureed peas - 116.8 F - pureed sweet potatoes - 133.7 F - mashed potatoes - 124.1 F - hamburger patty - 118.6 F CNA #11 was noted to plate the meals for the residents as per ticket, and if items had not reached the appropriate temperatures, she would reheat the plate with the food and the temperatures were re-documented. During this observation CNA #11 was noted to sanitize the thermometer in between temperatures and then place it in a cup of ice water each time after each was done. When asked why she did this, she said that this was how she was taught. Interview with CNA #11, in the Elm Cottage kitchen on [DATE] at approximately 11:30 AM, revealed she would normally place the hot holding heating electric wells temperature knobs between 8 or 9 setting. CNA #11 stated that she was trained by another CN[NAME] CNA #11 reported the food should be between 147 F - 177 F. CNA #11 also stated that she was supposed to reheat the food in the microwave until it reached a temperature of 145 F or 150 F or something. CNA #11 added that for the year she had worked at the facility, they never had any lids to use for the hot holding electric wells. Review of the documentation provided for both kitchenettes for the Cypress and Elm Cottages provided on [DATE], revealed (MONTH) 2019 through (MONTH) 3, 2019, staff had not been monitoring the internal temperatures of the French door refrigerator freezers. Review of several food temperature logs for the Cypress cottage revealed the following was documented: [DATE] - Lunch: Puree peas - 100.1 F - Dinner: Sweet peas - 134.6 F [DATE] - Lunch: Creamed corn - 120 F and Chicken - 120 F - Dinner: Green salad - 42 F and Pineapple - 48 F [DATE] - No hot or cold food temperatures documented for lunch or dinner [DATE] - Lunch: meat sauce -110 F and no temperature for the green beans - Dinner: no temperatures were documented for either cold or hot foods [DATE] - Lunch: Peaches - 48.8 F Review of several food temperature logs for the Elm cottage revealed the following was documented: [DATE] - Breakfast: Eggs - 134.2 F, Bacon - 107.5 F, French Toast - 122.3 F - Lunch: Baked Chicken - 129.7 F and Puree Meat - 118.1 F - Dinner: Curly fries - 130.4 F, Puree Meat - 125.5 F, Pineapples - 70.1 F [DATE] - Breakfast: Eggs - 132.6 F, Sausage - 128.2? F, Bacon - 102.1 F - Lunch - Mashed potatoes - 122.7 F and Chopped Meat - 120.8 F - Dinner: Grilled Cheese - 90.2 F [DATE] - No documentation done for cold or hot items for dinner [DATE] - Dinner: Potato salad - 62.1 F [DATE] - Breakfast: Puree meat - 112.2 F and Chopped meat - 115.5 F - Lunch: Puree meat - 130.5 F - Dinner: Broccoli - 134.8 F [DATE] - Breakfast: Sausage - 129.6 F and Bacon - 119.2 F - Lunch: Puree Meat - 81.6 F and Chopped Meat - 46.4 F - Dinner: no temperatures documented for either cold or hot [DATE] - Breakfast: Sausage - 134.5 F, Chopped meat - 100.6 F, Puree meat - 106.2 F - Lunch: Chopped meat - 128.2 F and Key lime pie - 50.1 F - Dinner: Puree meat - 98.2 F and Chopped meat - 98.1 F Further review of the Cypress and Elm Cottages food temperature logs revealed the staff filling out the document had not initialed or documented if corrective actions were taken. Hickory Cottage Observations: On [DATE] 11:11 AM, during observation of the Hickory Cottage lunch meal service, revealed the Dietary staff delivered metal pans of food items and placed some of the items inside the heated wells of the food service table and some of the food items on the outer edge of the food service table in an area which was not heated. CNA #1 was observed using a digital thermometer to take food temperatures from the heated food service table and record them on the Temperature Log and Checklist: The - String beans - 144.1 F - Chopped turkey - 114.6 F - Sliced turkey-120.9 F - Cornbread dressing- 143.6 F The following food items were stored on the outer edges of the food service table and not in the heated wells: - Chopped hot dog-106.0 F - Brown gravy- 133.8 F - Hot dog -106.0 F Food items stored on counter top in the kitchen were: - Grapes & strawberries - 68.0 F - Custard pie- 49.2 F There were no lids on the metal pans placed in the heated wells. There was an acrylic sneeze guard covering attached to the heat tables, above the food. On [DATE] 11:16 AM, after taking the temperatures of the food, CNA #1 was asked if she knew what the correct serving temperatures were. CNA #1 replied I know some of them, I don't know all of them. CNA, #2, who was assisting in the kitchen, was asked the same question and replied Yeah. I think it's at the bottom of the page, (referring to the Temperature Log and checklist). The meal service table was set at 3. When asked, how do you know what the heated food service table should be set at, CNA #1 replied The other Manager (he doesn't work here anymore) told us to turn the dials to 3. Without bringing the turkey and gravy up to a safe holding temperature, CNA #1 prepared a plate containing corn bread dressing with gravy, turkey and green beans for Resident #12, and was ready to serve the meal to the resident. Staff was asked to not serve and to have the Dietary Manager come over to the cottage before serving. On [DATE] at 12:34 PM, the Hickory Cottage refrigerator was observed to have multiple areas in the bottom freezer had food debris, melted brown ice cream droppings, and red stains on bottom food shelf. There were ice cream, frozen dinners and multiple bags of frozen fruit stored on wire racks above that area of the freezer. On [DATE] at 2:30 PM, in Hickory Cottage, Dietitian #6 was speaking with the CNA's concerning the use of the heated food service table. Dietitian #6 told the CNA's, You don't put water in them. When asked how the hot food service tables should be set-up, Dietitian #6 replied, We are looking into that now. On [DATE] at 11:25 AM, the Dietary Manager entered the kitchen and was made aware of the low holding temperatures on some of the food items being served for lunch. The Dietary Manager reviewed the temperature log and checklist and looked at the heated food service table and stated, There should be water in those containers on the table. When asked if she makes rounds to ensure the food items being served were at safe holding temperatures, the Dietary Manger replied, I make rounds and they use water in the other cottages. Oak Cottage - Observation: On [DATE] at 10:54 AM, during observation of the Oak Cottage kitchen refrigerator, there were scattered food particles in the bottom freezer storage area. The freezer area stored ice cream and snack bars. The glass drawer cover of the bottom drawer had a caked brown substance on it. Butter and other condiments were stored in the drawer. The stainless-steel garbage can at the entrance of kitchen had a heavy amount of brown, yellow, and white colored food residue on the lid. The wall behind the garbage can had multiple spill/drip marks on it. On [DATE] at 11:49 AM, observation of the Oak Cottage meal service, with the Dietary Manager, revealed there was no water in the food wells of the heated food service table. The cornbread dressing and turkey pans were uncovered on the counter in the kitchen. Residents were seated at the table eating their lunch. Review of the temperature log and checklist for [DATE], revealed the following recorded temperatures: - Chopped meat (turkey) - 139 F - Cornbread dressing- 158 F - Turkey- 134 F - Green beans- 150 F - Pureed: carrots- 134 F - Pureed meat (turkey) -130 F - Pureed green beans -104 F - Pureed gravy-130 F During an interview on [DATE] approximately at 11:49 AM, Licensed Practical Nurse (LPN) #4 stated, The Dietary Manager who use to work here before, told us we didn't need any water because there was no way to get the water out, we were just told to turn it on. During an interview on [DATE] approximately at 11:49 AM, CNA #3 and CNA #5 both stated, We were never told to put water in that table, because if we were told we would have done it that way. The Dietary Manager replied, No one ever told you to put water in there, if you don't put water in it, it can't keep the food hot. I need to get pans for you to put water in them, I guess. During the continued interview on [DATE], CNA #3 was asked what she would consider to be safe temperatures to serve the food during review of the temperature log and checklist. CNA #3 replied, I would say 130 degrees. Located in the lower left-hand corner of the temperature was the following information Minimum Holding Standards: Hot Beverages & Soups >/= 150 degrees, Hot food items: 140 - 165 degrees, Cold food & Beverage CNA #3 and CNA #5 were queried about who taught them how to set-up the heated food service table. CNA #3 replied, The CNA who use to work over here showed me. CNA #5 nodded her head in agreement. The CNAs did not identify CNA #7 (CNA trainer) as the person that provided their training. An interview at 11:00 AM on [DATE], with CNA #5, revealed housekeeping mops the floor. An observation of the cottage kitchen area, during the interview, revealed soiled areas inside of the refrigerator. Both CNA #3 and CNA #5 responded, Oh that needs to be clean, the night shift is supposed to do that when they clean the wheelchairs. When asked if there was a cleaning schedule, CNA #3 looked around the kitchen and then replied I don't know anything about a cleaning schedule. During an interview on [DATE] at 9:23 AM, the Dietary Manager stated, We prepare and deliver the food from our kitchen. We temp our food before we deliver the food to make sure it is at the right temperature. Our staff is not responsible for setting the heat tables up and temping the food after they are delivered to the cottages. Our staff is not responsible for putting the food in the wells. The CNAs are to do that. Staff is supposed to turn the wells on high when they first get in and once they get hot, turn it down to medium heat. We are responsible for the lids and the dividers. Only one (1) of the cottages had the lids, they are supposing to tell me if they don't have lids or dividers. We bring the temp logs over to the main kitchen and I keep them and review them. We do the dishes after the meal. I don't do the education for staff, they are responsible for that. I have just done what my boss have done in the past. I guess I need to speak to the Administrator and talk about what her expectations of us are. On [DATE] at 10:00 AM, Dietitian #6 was queried as to what his responsibilities were as far as food service and training of staff at the nursing home. Dietitian #6 replied, I am mostly clinical, I am involved in the food service, but the training and the set-up is mostly done by the Food Service Director and Manager who is relatively new in her position, a little over a month. On [DATE] at 9:43 AM, in an interview, the Administrator stated, When they are first hired, our Dietitian teaches them about safe-serve, portion sizes and food temps. The Nurse Educator does safe-serve education and the CNA is paired with another CNA who also trains them about the kitchen duties. The Dietitian does cottage visits. The Administrator further stated, Staff knows I have high standards. CNA's should be cleaning out the refrigerators, we don't have a cleaning schedule. Ice machines, garbage cans and the kitchen walls are done by housekeeping. These areas are cleaned monthly by housekeeping. An interview was conducted on [DATE] at 1:04 PM, with CNA #7, who is also responsible for CNA training. CNA #7 stated, I was trained by the on previous Dietitian. I do a walk through in the kitchen and show them how the heat tables work, how to take the temperatures, and I let them know the temperatures for the hot food should be at 140 degrees F and the cold food items should be at 41-degrees F or below. I tell them if the food doesn't reach those temps, call Dietary and inform them that the food is not correct. I tell them to turn the heat tables on an hour or so before the food comes; the setting on the tables should be between 5 and 6. Dietary comes and set the food up, do the food temps, and serve, and keep the food covered up until then. In some of the cottages they had covers, I was always told that the food had to be covered. Only time I go over to the cottages is if I get a complaint that someone doesn't know what they are doing. |
2020-09-01 |