Central Baptist Village

Inspectors wroteBased on interview and record review, the facility failed to provide written notice of the facility's bed-hold policy to the resident and/or resident representative at the time of transfer to the hospital or within 24 hours of transfer for two (R1, R2) of three residents reviewed for hospital transfers; the facility also failed to complete a discharge summary/recapitulation of stay when R1 and R2 did not return to the facility and were discharged from the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to perform hand hygiene when providing resident care and failed to ensure staff adhered to Enhanced Barrier Precautions. This applies to 6 of 6 (R3, R4, R6, R44, R81, and R8) residents reviewed for infection control in a sample of 25.

Inspectors wroteBased on observation, interview, and record review, the facility failed to assist residents with feeding in a dignified manner. This applies to 3 of 3 residents (R56, R83, and R79) reviewed for dignity in a sample of 25.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide ADL (Activities of Daily Living) cares for residents who require assistance with their ADLs. This applies to 2 out of 2 residents (R5 and R64) reviewed ADLs in a sample of 25.

Inspectors wroteBased on observation, interview, and record review, the facility failed to apply left and right palm protectors as ordered by physician. This applies to 1 resident (R76) reviewed for range of motion and contractures in a sample of 25.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide catheter care in a manner to prevent urinary tract infections for a resident with an indwelling urinary catheter. This applies to 1 resident (R8) reviewed for urinary catheters in a sample of 25.

Inspectors wroteBased on observation, interview, and record review the facility failed to aspirate gastric contents to check the placement of a resident's gastrostomy tube (GT). This applies to 1 of 1 (R3) residents reviewed for GT care in a sample of 25.

Inspectors wroteBased on observation, interview and record review the facility failed to administer medications as ordered. There were 30 opportunities with 3 errors resulting in a 10% error rate. This applies to 1 of 5 residents (R17) observed in medication pass.

Inspectors wroteBased on the interviews and record reviews, the facility failed to provide the required staff assistance for bed mobility and ambulation for dependent residents as per the MDS (Minimum Data Set) assessment. This applies to 2 of the 3 residents (R1 and R2) reviewed for resident falls and injuries in a sample of 3. The Findings Include: 1. R1 is an [AGE] year-old female admitted on the dementia floor on 8/18/22 with an admitting diagnosis, including vascular dementia and multiple sclerosis. On 12/31/24 at 9:25 AM, R1 was observed in her bed and was unable to move her lower extremities except wiggling toes. On 12/31/24 at 9:25 AM, R1 stated, I had a fall to the right side of my bed. My leg didn't move the way I want to. I don't remember what my CNA was doing at that time. A review of R1's fall risk assessment dated [DATE] document that R1 is high risk for fall. [...]

Inspectors wroteBased on interview and record review, the facility failed to document and track HCP (Health Care Providers) covid test results during a covid outbreak in accordance with their policy. This applies to all 102 residents who reside in the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to serve portions of Garlic Herb Roasted Pork Tenderloin to residents receiving mechanically altered diets as planned on the approved facility menu. This applies to 5 of 5 residents (R1, R41, R52, R62, and R87) reviewed for portion sizes.

Inspectors wroteBased on observation, interview, and record review, the facility failed to offer/provide residents food substitutions equivalent in nutritive value to the originally planned/served menu items. This applies to 4 of 4 residents (R54, R57, R83, and R96) reviewed for food substitutions.

Inspectors wroteBased on observation, interview, and record review the facility failed to follow a resident's plan of care to prevent and treat the development of facility-acquired pressure wounds for a resident at high risk for pressure wounds. This applies to 1 of 4 residents (R25) reviewed for facility-acquired pressure injuries in the sample 21.

Inspectors wroteBased on observation, interview, and record review the facility failed to follow their policy to administer medications as ordered by the physician. There were 33 opportunities with 3 medication administration errors resulting in a 9.09% medication error rate. This applies to 2 of 4 residents (R65, R73) reviewed for medication administration in the sample of 21.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food was prepared in a manner to prevent cross-contamination for 4 of 4 residents (R15, R35, R83 and R88) reviewed for pureed foods in the sample of 21, and 4 residents outside the sample (R5, R54, R74, and R90).

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure privacy was provided for a resident during care for 1 of 1 resident (R47) reviewed for privacy in the sample of 21.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop a care plan in a timely manner to address a pressure injury for 1 of 3 residents (R44) reviewed for pressure in the sample of 21.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide a safe transfer for 1 of 1 resident (R107) reviewed for safety and supervision in the sample of 21.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a residents indwelling urinary catheter drainage bag was not on the floor for 1 of 2 residents (R50) reviewed for catheters in the sample of 21.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure weekly weights were obtained for 1 of 8 residents (R44) reviewed for nutrition in the sample of 21.

Inspectors wroteBased on observation, interview and record review the facility failed to prevent cross contamination of resident contact surfaces by not removing gloves and washing hands after providing incontinence care for 3 of 3 residents (R107, R47, & R35) reviewed for infection control in the sample of 21.