4Angels Of Byromville Healthcare Center

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interviews, the facility failed to ensure a safe, clean, and comfortable environment was maintained for four of four resident rooms (Rooms 101, 102, 103, and 107). The facility census was four residents. These deficient practices had the potential to place the residents at risk of living in an unsanitary and unsafe living environment and a potential for diminished quality of life.
Findings include:
Observations on 9/10/2024 at 8:14 am revealed the ceiling intake vents in resident rooms [ROOM NUMBERS] had heavy dust buildup.
Observation on 9/10/2024 at 8:20 am of resident room [ROOM NUMBER] revealed the toilet bowl had a dark gray thick substance buildup and the paper towel holder was broken. Further observations during the survey revealed the buildup remained in the toilet bowl.
Observations from 9/10/2024 through 9/12/2024 revealed the heavy dust buildup on the ceiling intake vents in resident rooms [ROOM NUMBERS] remained throughout the survey period.
Further observation of resident room [ROOM NUMBER] revealed a light fixture over the sink with a rough brown substance, the sink had grayish chipped areas, the wall base underneath the bathroom sink was peeling and lifting, the back of the room door was cracked, the wall to the left of the room door was noted with the wall base peeling and lifting, and the wall had chipped cracked areas.
Interview on 9/11/2024 at 8:35 am, the Administrator stated the substance in the toilet bowl in resident room [ROOM NUMBER] was from the toilet not being used for over a year. She stated the toilet was not replaced prior to admitting a resident in the room because the resident currently in the room did not use the bathroom. She said she planned to replace the toilet when the facility had more residents. The Administrator verified the thick, dark gray buildup in the toilet bowl.
During walking observation rounds on 9/12/2024 at 12:15 pm, the Administrator verified the findings in resident rooms [ROOM NUMBERS]. She further stated housekeeping was responsible for cleaning the ceiling vents but if they could not reach the vents, maintenance was responsible for cleaning them. The Administrator stated the Maintenance Director was on vacation and unavailable for an interview.
Observations of resident room [ROOM NUMBER] on 9/10/2024 at 9:00 am, 9/11/2024 at 9:10 am, and 9/12/2024 at 12:31 pm revealed brown stained areas on the ceiling tiles, brown discoloration on the ceiling in the shape of a privacy curtain track, and a four-inch crack in the bathroom door.
Interview on 9/12/2024 at 12:31 pm, the Administrator confirmed the findings in resident room [ROOM NUMBER]. The Administrator stated the ceiling tiles needed to be painted, and she did not know how to fix the door.
Observations of resident room [ROOM NUMBER] on 9/10/2024 at 9:00 am, 9/11/2024 at 9:10 am, and 9/12/2024 at 12:00 pm revealed an eight-inch crack behind the front entrance door of the resident room and no cold running water from the bathroom faucet.
Interview on 9/12/2024 at 12:31 pm, the Administrator confirmed the findings in resident room [ROOM NUMBER]. She stated she would discuss the findings with the Maintenance Department.

Based on observation, staff interview, and review of the policy titled, Food Preparation and Service, the facility failed to discard food in the refrigerator by the use by date and failed to label opened food items in the freezer. The deficient practice had the potential to place four residents who received an oral diet from the kitchen at risk of contracting a foodborne illness.
Findings include:
Review of the facility policy titled Food Preparation and Service, revised November 2022, revealed the Policy Statement of Food and nutrition employees prepare, distribute and serve food in a manner that complies with safe food handling practices. The Food Storage after opening section stated, Follow the following food storage guidelines after opening: . 6. Salads, Coleslaw, are to be kept for 3 to 4 days.
During a tour of the kitchen on 9/10/2024 at 9:50 am, observation in one refrigerator revealed one bag of coleslaw with an expiration date of 9/6/2024, one package of chicken breast lunch meat with an expiration date of 7/14/2024, one head of lettuce with a handwritten stored date of 9/2/2024, and one bag of lettuce with a handwritten stored date of 9/2/2024 and an expiration date of 9/5/2024. Observation of the freezer revealed a bag of two chicken breasts that were not labeled or dated.
Interview on 9/10/2024 at 12:20 pm, the Dietary Manager (DM) revealed that all expired food should be discarded on or before the expiration date. She revealed she did not know the facility policy on labeling and dating food and had not received any updated policies since the new owner took possession of the facility in May 2024.
Interview on 9/12/2024 at 12:13 pm, the Administrator revealed she would expect the DM to discard all expired food or drink items. The Administrator revealed she was unsure about labeling food items and she thought three days was the most an item should be stored once opened. She stated dietary staff should label and date all food and drink items when opened.

Based on observation and staff interviews, the facility failed to ensure resident protected health information was inaccessible to non-essential staff. This deficient practice placed the residents at risk of unauthorized staff having access to their protected health information. The facility census was four residents.
Findings include:
Observation on 9/11/2024 at 2:35 pm revealed two large rolling carts with resident charts containing clinical information were located in the laundry room. The charts were visible and accessible to anyone in the laundry room.
Interview on 9/11/2024 at 3:00 pm, housekeeping staff stated the charts belonged to previous residents who were discharged due to the facility closing and further stated the charts were left behind.
Interview on 9/12/2024 at 3:45 pm, the Administrator stated she was unaware the resident charts were stored in the laundry room and would take care of them.
Interview on 9/12/2023 at 3:48 pm, the Director of Nursing (DON) revealed the facility didn't have a policy on storing medical records.

Based on observation, staff interviews, and review of the facility policy titled Laundry and Bedding, Soiled, the facility failed to ensure the storage and processing of linens and clothing to produce hygienically clean laundry and prevent the spread of infections and cross-contamination risk for four of four residents. These failures had the potential to expose residents to infections due to cross-contamination.
Findings include:
Review of the facility policy titled Laundry and Bedding, Soiled, revised September 2022, revealed the Policy Statement was Soiled laundry/bedding shall be handled, transported and processed according to best practices for infection prevention and control.
Observations on 9/11/2024 at 2:30 pm in the laundry room revealed two rolling carts with a buildup of dust, trash on the floor, one ladder, one table, old furniture, one cart with nails and paint, and one folded black cloth present on the laundry folding table. All objects were covered with a buildup of dust. Further observation revealed the hand washing sink in the laundry room had a buildup of brown substance.
Interview on 9/12/2024 at 2:45 pm, the Administrator verified the findings in the laundry room and stated the condition of the laundry room was unacceptable. The Administrator confirmed the findings in the laundry room were infection control concerns and stated the findings would be corrected.

Based on staff interviews and record review, the facility failed to have the Antibiotic Stewardship Program acknowledged by the Pharmacist and Medical Director. This deficient practice had the potential to affect all residents residing in the facility. The facility census was four residents.
Findings include:
Review of the Antibiotic Stewardship Program documents revealed there were no antibiotic stewardship acknowledgment forms for the Pharmacist or the Medical Director to acknowledge their accountability.
Interview on 9/12/2024 at 4:12 pm, the Director of Nursing (DON)/Infection Preventionist (IP) revealed the facility did not have an acknowledgment form for the Pharmacist or Medical Director for the facility's Antibiotic Stewardship Program.
Interview on 9/12/2024 at 4:15 pm, the Administrator revealed the facility did not have the acknowledgment forms for the Medical Director and the Pharmacist for the facility's Antibiotic Stewardship Program.