Baptist Nursing Home-Calhoun, Inc

Inspectors wroteBased on observations, interviews, record reviews and policy and procedure reviews, the facility did not follow established infection control procedures for the transportation, handling, and disturbing of dirty and clean linens. The facility used the public laundry and transported the dirty and clean linens in the facility van that was for resident use without cleaning the van/bus before and after each use. The facility also used public washing machines without cleaning them before and after each use and for not using hot water temperatures in accordance with infection control policies and procedures. The deficient practice had the potential to affect 93 of 93 residents living in the facility and all staff. Findings Include:The facility policy titled: Laundry Services undated, read: To assure a clean supply of linens and to protect employees who handle and process the laundry. [...]

Inspectors wroteBased on resident interviews, staff interviews, record reviews, observations, policy and procedure reviews, local county sheriff's report and interview, and review of the social media video, the facility failed to ensure that the rights of Resident #1 to have respect and dignity were honored when two Certified Nursing Assistants (CNAs) taunted, threatened and abused Resident #1 and posted the videos to social media. Resident #1 was one (1) of three (3) residents that were reviewed for Resident Rights. The evening of 07/22/25 two (2) facility Certified Nursing Assistants (CNA)'s posted a video to social media in which they taunted, threatened and abused Resident #1. The video was seen by the community and the family of the resident. [...]

Inspectors wroteBased on staff interviews, observations, resident interviews, record reviews, policy and procedure reviews, video review, and sheriff's arrest report review, the facility failed to protect Resident #1's right to be free from abuse when staff created a video during care of the resident, of verbal and physical abuse, of the resident and posted it to social media. Resident #1 was one (1) of three (3) residents reviewed for Abuse and Neglect. The evening of 07/22/25 two (2) facility Certified Nursing Assistants (CNA)'s posted a video to social media in which they taunted, threatened and abused Resident #1. The video was seen by the community and the family of the resident. [...]

Inspectors wroteBased on observation, resident and staff interviews, record review, and facility policy review, the facility failed to implement a comprehensive care plan for 1) for Resident #16 who was a known risk for sexual behaviors towards others, to prevent the resident from entering Resident #56's room and sexually assaulting her while she lay in her bed, 2) transfer assistance for a dependent resident (Resident #5), and 3) assistance with Activities of Daily Living (ADL) (Resident #40, #90, and #92) for five (5) of 22 resident care plans reviewed. Resident's # 5, #16, #40, #90 and #92. [...]

Inspectors wroteBased on staff interviews, record review, and facility policy review, the facility failed to ensure quarterly Quality Assurance and Performance Improvement (QAPI) committee meetings were held at least quarterly with the mandatory staff present for two (2) of the most recent four (4) quarters.

Inspectors wroteBased on resident and staff interview, record reviews, and facility policy review, the facility failed to promptly resolve grievances regarding cold food for four (4) of six (6) residents present in Resident Council. (Resident #34, # 37, #47, and #84) Findings Include: Review of facility policy titled, Patient Complaint and Grievance Policy effective date 3/18, last review date 1/22, revealed, Policy: Providing quality services is the primary objective .Feedback and comments received by patients or their representatives provide the organization with opportunities for improvement and enhancements of services. Patients and/or their representatives have the right to voice concerns verbally or in writing when their expectations are not met . [...]

Inspectors wroteBased on staff interview, record review, and facility policy review, the facility failed to carry out a physician ordered gradual dose reduction (GDR) for one (1) of five (5) residents reviewed for medication. Resident #64 Findings Include: Review of the facility policy titled Resident's Rights and Privileges with no revision date revealed, 21. Freedom from Chemical and Physical Restraints: Residents in the proper name of the facility shall enjoy freedom from chemical or physical restraints . Record review of the Consultant Pharmacist Recommendation dated September 3, 2024, revealed the physician ordered a decrease in Resident #64's Effexor (antidepressant) from 75 milligrams daily to 37.5 milligrams daily. [...]

Inspectors wroteBased on observation, staff interview, and record review, the facility failed to accurately complete section P of the Minimum Data Set (MDS) for one (1) of 22 sampled residents. Resident #19 Findings Include: The facility provided a statement on letterhead that revealed, MDS (Minimum Data Set) at proper name of the facility follows the RAI (Resident Assessment Instrument) Guidelines. Record review of the MDS with an Assessment Reference Date (ARD) of 4/03/25 revealed under section P, a bed rail was coded as a physical restraint that was used daily. An observation on 4/29/25 at 11:27 AM revealed Resident #19 with no type of restraint in use. Record review of Resident #19's Restraint Usage Evaluation dated 4/03/25 revealed under, Has any type of restraint been used in the past 7 days? No was indicated. [...]

Inspectors wroteBased on observation, resident and staff interviews, record review, and facility policy review, the facility failed to provide care to maintain personal hygiene for three (3) of 95 residents in the facility. Resident #40, #90, and #92.

Inspectors wroteBased on observation, staff interview, and facility policy review, the facility failed to ensure medications were stored appropriately for one (1) of 95 residents residing in the facility. Resident # 32 Findings Include: Review of the facility policy titled Administration for Oral Medications unrevised, revealed under, Policy: It is the policy of proper name of the facility that all services provided or arranged by the facility must meet professional standards of quality. Record review of the Nursing Department QA (Quality Assurance) for Med Pass revised 2/15/12 revealed, Ensure that resident has taken and swallowed medication. An observation of Resident #32 on 4/29/25 at 11:40 AM revealed she was lying on her left side in bed with her eyes closed. A clear medication cup was observed sitting on the bedside table with seven (7) pills inside. [...]

Inspectors wroteBased on observation, staff interview, and facility policy review the facility failed to put infection control measures in place to prevent the possible spread of infections for one (1) of 95 residents residing in the facility.

Inspectors wroteBased on staff interviews, record review and facility policy review, the facility failed to protect the resident's right to be free from sexual abuse for one (1) of 20 residents on the Special Care Unit. Resident #56. Resident #56 was found on 4/24/25 at approximately 3:00 PM, by a Certified Nursing Assistant (CNA) with Resident #16 in the bed and on top of her, with his hand inside her incontinence brief, performing jabbing motions. Resident #16 became violent with the staff when they tried to remove him from Resident #16's room where he hit a staff member with his fist. The facility's failure to prevent the sexual abuse of Resident #56 placed Resident #56 and other residents at risk for sexual assault, in a situation that caused and was likely to cause serious injury, serious harm, serious impairment, or death. [...]

Inspectors wroteBased on record review, staff interviews, and facility policy review, the facility failed to report alleged violations of sexual abuse that occurred within the two (2) hour timeframe to the proper authorities for one (1) of one (1) allegations of sexual abuse. Resident # 56 On 4/24/25 at approximately 3:00 PM, Resident #56 was found by a Certified Nursing Assistant (CNA) with Resident #16 in the bed and on top of her, with his hand inside her incontinence brief, performing jabbing motions. Resident #16 became violent with the staff when they tried to remove him from Resident #16's room where he hit a staff member with his fist. [...]

Inspectors wroteBased on staff interview, record review, and facility policy review the facility failed to ensure a resident was free from accident hazards when the facility failed to ensure staff transferred the resident with the proper assistive devices for one (1) of three (3) residents reviewed for accidents. Resident #5. Findings Include: Record review of the facility policy Falls Management revealed It is the goal of [Proper Name of Facility] to assure that our residents remain free of accident hazards as possible and that each resident receives adequate supervision and assistive devices as needed to prevent accidents. Record review of the facility investigation revealed that on 1/27/25 at approximately 1:35 PM Resident #5 was being assisted from her bed to the wheelchair by two (2) Certified Nursing Assistants (CNA), her legs got weak, and the CNAs assisted her to the floor. [...]

Inspectors wroteBased on staff interview, record review and facility policy review, the facility failed to notify a Resident Representative (RR) following an accident for one (1) of three (3) residents reviewed for notifications of change. Resident #5. Cross Reference F689, F656 Findings Included: Record review of the facility policy titled Notification of Changes revealed, Policy: i. To immediately notify the resident, consult with the resident's physician, and if known, notify the resident's legal representative or interested family member when: a. An accident involving the resident which results in injury or has the potential for requiring physician intervention . [...]

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure food was stored and served under sanitary conditions, when staff failed to remove perishable food items, including milk, from the resident's room in a timely manner. This resulted in the potential for foodborne illness due to prolonged exposure of food to room temperature for one (1) of five (5) days of survey. (Resident #90)

Inspectors wroteBased on staff and resident interview, record review and facility policy review the facility failed to follow up and resolve grievances regarding residents' complaints related to cold food for two (2) of six (6) resident's present during the resident council meeting, Residents #15, and Resident #45, and failed to provide the residents with a way to file a grievance for six (6) of six (6) residents present during the resident council meeting. Residents # 6, Resident #15, Resident #44, Resident #45, Resident #49, and Resident #71.

Inspectors wroteBased on observation, staff interview, record review and facility policy review the facility failed to implement a person-centered care plan for a resident to be up in her chair for all meals (Resident #70) and to monitor for side effects of an anti-coagulant (Resident #84) for two (2) of 20 care plans reviewed.

Inspectors wroteBased on observations, staff interview, record review and facility policy review the facility failed to get a resident up in her wheelchair for all meals; for a resident that required assistance with their Activities of Daily Living (ADL) for one (1) of 20 resident's reviewed for ADLs.

Inspectors wroteBased on staff interviews, record review and facility policy review, the facility failed to monitor a resident on a physician prescribed anticoagulant medication for signs of bruising or bleeding for one (1) of five (5) residents reviewed for unnecessary medication. Resident # 84.

Inspectors wroteBased on staff interviews and record review the facility failed to provide a written notice of transfer to the resident and the Resident Representative (RR) for three (3) of three (3) residents reviewed. Resident #22, #83, and #89.

Inspectors wroteBased on staff interview and record review, the facility failed to provide bed hold notification to residents or Resident Representatives (RR) for residents sent out to an acute care facility for two (2) of three (3) residents reviewed for bed hold. Resident #22 and #83.