Every finding on record at Treutlen County Health and Rehabilitation

Based on observations, staff interviews, and review of the facility policies Hand Hygiene and Infection Control at a Glance, the facility failed to follow infection control practices by not covering clean linen during transport and distribution, creating a risk of cross contamination for the census of 50 residents. In addition, the facility failed to perform hand hygiene during wound care for one of two sampled residents (R9).Findings include: 1.Review of the facility's policy titled Infection Control at a Glance undated, documented Goal: To have a comprehensive program that addresses detection, prevention, and control of infections among patients and associates. Purpose: Decrease the risk of infection to patients and associates. Monitor for occurrence of infection and implement appropriate prevention measures. Identify and correct problems relating to infection prevention practices. Monitor compliance with state and federal regulations relating to infection prevention. Review of the facility's policy titled Hand Hygiene reviewed 12/27/2025 documented INTENT: It is the intent of this facility to promote and facilitate appropriate hand washing as set forth by the guidelines of CDC. PURPOSE: Hand Hygiene is the single most important means of preventing the spread of infection. The use of gloves does not replace hand washing. GUIDELINE: Associates should use alcohol based hand rub or wash hands with soap and water for the following indications: Immediately after glove removal. Glove use: Gloves should not be used as a substitute for hand hygiene.If your task requires gloves, perform hand hygiene prior to donning gloves, .Perform hand hygiene immediately after removing gloves. Review of the facility's Electronic Medical Records (EMR) revealed R9 was admitted to the facility on [DATE] with diagnosis included but not limited to encounter for attention to gastrostomy. Review of the Significant Change Minimum Data Set (MDS) revealed Section C (Cognition) Brief Interview for Mental Status (BIMS) of 01 which indicated R9 had severe cognitive impairment, Section K (Swallowing/Nutritional Status) documented R1 had feeding tube. Review of Care plan dated 03/03/2026 documented included but not limited to tube feeding related to swallowing difficulties and intervention to: Assess feeding tube placement, patency, and residual every shift and before and after administration of any fluids or medications. Review of Physician's Order dated 03/10/2026 documented included but not limited to Nutren 1.5 Oral Liquid 25 Milliliter / Hour PEG Tube every 24 hours. Observations on 03/21/2026 at 11:31 PM during gastrostomy tube (GT) medication administration revealed Registered Nurse (RN) CC changed gloves without sanitizing her hands on two occasions. Interview on 03/21/2026 at 11: 43 PM with RN CC revealed she confirmed she did not sanitize her hands between glove change. She stated she should have sanitized her hands when she removed her gloves and before she put on a new pair of gloves because germs may be on her hands and it may transfer to the new pair of gloves. She stated the resident would get sick or get an infection when she did not hand sanitize between glove change. Interview on 03/21/2026 at 5:10 PM with the Infection Preventionist revealed she stated her expectations were for the staff to sanitize their hands between glove change. She stated when gloves were removed, hands were to be sanitized or washed before another pair of gloves were put on. The IP stated when hands were not washed or sanitized between glove change a negative outcome would be the residents would be at risk for infection. Interview on 03/22/2026 at 11:11 AM with the Director of Nursing (DON) revealed she stated her expectations were for the staff to sanitize or wash their hands between glove change. She stated the staff were expected to sanitize their hands after removing gloves and before putting on a new pair of gloves. 2. Observations on 03/20/2026 at 11:00 AM and 03/21/2026 at 11:30 AM revealed a laundry aide transporting resident clothing from room to room without the laundry being covered, exposing the clean laundry/linens to residents, staff, and visitors ambulating throughout the hallway, making the laundry susceptible to airborne pathogens. Interview on 03/20/2026 at 11:50 AM with Laundry Aide DD revealed she usually covered the bottom of the cart where the clothes were folded but did not cover the hanging items. Interview on 03/20/2026 at 12:00 PM with the Director of Nursing (DON) and the Administrator revealed that per the facility's policy, clean laundry did not need to be covered for protection when transporting clean clothing/linens to resident rooms.

Based on observations, staff interviews, record reviews, and review of the facility's policy titled Medication Administration - General, the facility failed to follow accepted standards of practice for one of 20 sampled residents (R44). This deficient practice created a risk of infection and the potential to negatively affect R44's medical condition. Findings include:Review of the facility's policy titled Medication Administration - General, reviewed 04/15/2025, documented: INTENT: To facilitate that medications are administered as prescribed, in accordance with good nursing principles. Review of the facility's Electronic Medical Records (EMR) revealed R44 was admitted to the facility on [DATE] with diagnoses including, but not limited to, hypertensive heart disease, chronic kidney disease with heart failure, chronic kidney disease, and essential tremors. Review of the admission Minimum Data Set (MDS) dated [DATE] documented Section C (Cognition) Brief Interview of Mental Status (BIMS) score of 15, which indicated R44 had intact cognition. Section I (Active Diagnoses) documented R44 had hypertension. Review of the care plan dated 01/27/2026 documented a focus area for diuretic use related to spironolactone, with interventions to monitor for hypotension and signs and symptoms (s/s) of dehydration. Review of the Physician's Orders dated 01/13/2026 documented orders including, but not limited to, spironolactone 25 milligram (mg) tablet, 1 tablet by mouth 2 times per day *** BEST IF TAKEN WITH FOOD *** and primidone 50 mg tablet (PRIMIDONE) 1 tablet by mouth 2 times per day. Observation on 03/21/2026 at 11:11 AM revealed that during review of the B Hall medication cart, Licensed Practical Nurse (LPN) BB was present. Two tablets were on the bare surface of one drawer. LPN BB used her bare hands to remove the two tablets and placed them in the open packet among R44's other medications. The open packet was attached to the original packets of medications from the pharmacy. LPN BB looked at each tablet and compared them to the pharmacy packet to confirm the tablets were from R44's medication packets. She secured the packet of tablets with tape, including the two loose tablets from the surface of the medication cart drawer, folded the packets together, and placed the packet in the drawer among R44's other medications. LPN BB stood beside the medication cart and waited to proceed with the review of the cart. Interview on 03/21/2026 at 11:13 AM with LPN BB revealed she confirmed and validated that she removed the two tablets with her bare hands and placed them in the open packet with R44's other medications. She confirmed she taped the packet, folded it, and placed it among R44's other medications. LPN BB stated the tablets were spironolactone 25 mg and primidone 50 mg. LPN BB stated she could have administered the medications to R44 later in the shift if R44 was scheduled to receive them. She further stated that because she placed the loose tablets from the drawer into the packet with the other medications, secured them with tape, and folded the packets together in the medication cart among R44's other medications, another nurse could also administer the medications to R44. LPN BB further stated that if R44 received the tablets that had been on the surface of the drawer, R44 could get sick and develop an infection. Interview on 03/21/2026 at 5:10 PM with the Infection Preventionist (IP) revealed she stated that tablets must not be placed in bare hands because this would cause contamination of the tablets and create a potential risk for residents to develop infections. The IP further stated the medication drawer was not considered a clean surface, so medications from the surface of the drawer must not be placed in packets and secured to be given to residents. She stated that if residents received such medications, they could develop infections. Interview on 03/22/2026 at 8:56 AM with Registered Nurse (RN) CC revealed she stated that when tablets were on the surface of the medication cart drawer, they were not to be placed back in the residents' medication packets or placed in the drawer where other medications were kept. She stated the medication cart drawers were not clean and that this was an infection control issue. RN CC further stated the residents could get sick or develop infections if they were given such medications. Interview on 03/22/2026 at 11:11 AM with the Director of Nursing (DON) revealed she stated her expectations were for nurses to follow correct protocol regarding loose medications found in the medication carts and to ensure they were not placed back into circulation.

Based on staff interviews, record review, and a review of the facility's policy titled Abuse Prohibition, the facility failed to protect the resident's right to be free from physical abuse by facility staff for one of three residents (R) (R1) reviewed for abuse. The abuse had the potential to affect all residents residing in the facility at that time. Findings included:Review of the facility's policy titled, Abuse Prohibition with review date 4/7/2025 revealed, It is the intent of this center to actively preserve each patient's right to be free from mistreatment, neglect, abuse or misappropriation of patient property. We believe that each patient has the right to be free from verbal, sexual, physical and mental abuse, corporal punishment, and involuntary seclusion. The purpose of these identified procedures is to assure that we are doing all that is within our control to create a standard of intolerance and to prevent any occurrences of any form of mistreatment, neglect, abuse or misappropriation of any patient and/or their property. The procedures herein establish standards of practice for protection of patients and for identification and prevention of abuse. This policy applies to anyone subjecting a patient to abuse including, but not limited to, center staff, other patients, consultants or volunteers, staff of other agencies serving the individual, family members or legal guardians, friends, or other individuals.A record review revealed R1 had a primary diagnosis of Alzheimer's disease with early onset. Other diagnoses included, but not limited to, dementia in other diseases classified, pain, and generalized anxiety disorder. R1 resided on the C Hall.Review of the facility-reported incident revealed a Facility Incident #202505379, dated 5/25/2025, that documented an allegation of staff-to-resident abuse. The form included that the allegation involved R1 and a Certified Nursing Assistant (CNA CC). Further review of the form revealed that the police were called, interviewed CNA CC, and escorted CNA CC to her car. The facility suspended CNA CC's CC upon her exit, pending an investigation, until further notice. CNA CC had no further contact with residents following the incident. Interview with two witnessing CNAs reported that R1 became combative during care and struck out at staff. CNA CC responded to the aggression by hitting R1 in the face. The charge nurse performed a head-to-toe assessment and reported redness to the left side of R1's face. The physician and responsible party were notified of the incident and redness to R1's face. The physician ordered an X-ray, which showed no adverse findings. A pain and behavior assessment was also performed, with no pain noted and no psychosocial trauma. Review of the (named law enforcement) assault report dated 5/30/2025 revealed the Offenses was Statute 16-5-100-Curelty to a person [AGE] years of age or older. A review of the accompanying investigation included a 5-day follow up report to the State Agency, Police assault report, incident report, resident interview and skin assessments, staff education, letter to families, termination of CNA CC, audit clinical assessments, weekly audits, witness statements, staffing for the time of the incident, and QAPI Ad Hoc notes. The conclusion summary of the investigation revealed that, based on witness statements and physical symptoms noted during assessment, there was enough evidence, and the facility substantiated that CNA CC physically abused R1.Review of the 5-day follow-up report dated 5/27/2025 revealed CNA CC had been terminated. CNA CC had also been arrested and charged with Elder Abuse. Follow-up Social Service note dated 6/25/2025 documented R1 was wandering throughout the facility as desired. R1 reported she felt safe in the environment, appetite was good, sleeping well, no delusions, no anxiety, no change in sleep patterns or physical aggression was noted.Review of the Quarterly Minimum Date Set (MDS) assessment dated [DATE] revealed Section C-Cognitive Patterns, there was no BIMS (Brief Interview for Mental Status) score reported because R1 was rarely/never understood, had short and long-term memory problem, and severely impaired cognitive skills for daily decision-making, indicating R1 never/rarely made decisions. Section D -Mood was not completed, R1 declined to respond to questions.Section G Functional Status revealed R1 was independent to limited assist. R1 did not have any impairment to her upper extremities or her lower extremities on either side. Review of the care plan, revised date 5/27/2025 revealed that R1 had potential for trauma due to (d/t) experience with healthcare worker dated 5/27/2025 related to history of trauma experience by healthcare worker, history of abuse/neglect. An observation and interview were attempted on 12/22/2025 at 8:39 am with R1, who was very confused and did not respond appropriately, if at all, to questions. Additional observations during the survey revealed R1 ambulating aimlessly throughout the facility. R1 never spoke or answered any simple, short questions.An interview on 12/22/2025 at 8:10 am during a brief entrance conference with the Assistant Director of Nursing (ADON) confirmed that the allegation that R1 was struck was substantiated. The ADON stated the facility reported it to the State Agency and the police.Interview on 12/22/2025 at 9:42 am with the Administrator confirmed that the abuse of R1 by CNA CC was investigated and substantiated that it occurred. She submitted a self-reported incident report and provided it for review. The Administrator stated that CNA CC reported she only tapped R1 on the forehead because R1 hit CNA CC in the mouth, but it doesn't matter what a resident does. Her expectation was that staff should never put their hands on a resident or touch them inappropriately.Past noncompliance as evidenced by:1.5/25/2025 - R1 was kept safe and monitored closely after the incident.2. 5/25/2025 - CNA CC was kept at the nurses' station under watch until police arrived.3. 5/25/2025 - The physician, family, and police were notified. 4. 5/25/2025 - Staff gave written statements. 5. 5/25/2025 - Police interviews and escorted CNA CC to her vehicle, and she left the premises.6. 5/25/2025 - The door code was changed, and CNA CC is not allowed back into the facility.6. 5/25/2025 - CNA CC was suspended during investigation. 7. 5/27/2025 - CNA CC was terminated. 8. 5/27/2025 - Police arrested CNA CC, and she was charged with Elder abuse.9. 5/25/2025 - 5/27/2025 All residents in the facility were assessed, and interviewable residents were interviewed and asked if they felt afraid of anyone or if they felt safe. 10. 5/26/2025 - The incident was included in QAPI for discussion, review, and monitoring.11. Beginning 5/25/2025 -Weekly audits were conducted for four weeks, and an interview with the Administrator revealed they would have gone longer if they felt it was needed.12. Beginning 5/25/2025 - Weekly interviews and assessments were conducted to all residents.13. 5/27/2025 - Letters were sent out to families. 14. 5/25/2025 -At the time of the complaint visit, staff monitored R1 closely and assisted as needed.15. 5/25/2025 and 5/26/2026 - Staff education and training. Staff were instructed on how to work with R1 as well as all residents with dementia/Alzheimer's/mental disease, Abuse and neglect.

Based on observations, staff interviews, and review of the policy titled Skilled Inpatient Services - Storage Areas, the facility failed to ensure that items were discarded after the use by/best buy/expiration date, that food on the steam table remained in safe temperature range during serving, items were placed in a clean container with a tight fitting lid when remove from the original packaging, chipped paint, and the kitchen was clean as evidenced by buildup on the back of stove, light covers, and a wall and door near a trashcan. This deficient practice impacted 40 of 42 residents who received oral diets. Findings include: Review of policy titled Skilled Inpatient Services - Storage Areas, dated [DATE], revealed: Guideline - All items should be inspected for quality and temperature control upon receipt. Items should be covered, sealed, labeled, and dated appropriately. First in first out (FIFO) should be followed. Freezer - Area should be kept in good working condition. During initial kitchen tour and interviews on [DATE] at 7:45 a.m. with the Assistant Dietary Manager and the Certified Dietary Manager (CDM) the following was identified: 1. In the main kitchen the can opener was noted to have a black sticky substance on the blade and holder. There were also food substances noted on the side of the table where the can opener was attached. 2. In the main kitchen there were two white containers with buildup on the front and top that contained sugar and corn meal. 3. In the main kitchen there was a door and wall near the trashcan that had food build up and spills noted. 4. In the dry storage food area there were plastic containers container penne pasta with a use by date of [DATE] written on the label, egg noodles with [DATE] written on the label, and cous cous with a use by date of [DATE] written on the label. 5. In the microwave there was food splatter in the top and on the sides of the inside of the microwave. 6. In the walk-in cooler there were seven containers of heavy whipping cream with a use by date of [DATE]. 7. In the dry food storage there was a 12 pack of hot dog buns that were not dated with an expiration date. The CDM reported that the can opener should be cleaned on Wednesdays and confirmed the black build up and food. CMD reported that the items in the containers in dry storage were just ordered and staff are not putting the correct dates on the containers as they are refilled. Assistant Food Manager reported that he was responsible for updating the labels on the items in the kitchen and he had not done so. He explained that items should have expiration dates on them. He then reported that the hot dog buns should have been in the freezer and not in the dry food storage area but confirmed that there was no way to determine the expiration date of the hot dog buns. Servery Kitchen tour on [DATE] at 8:16 a.m. revealed the following: 1. There were two containers of thickened apple juice with a best if used by date of [DATE]. 2. There were two containers of thickened water with a best if used by date of [DATE]. Interview and observations conducted on [DATE] beginning at 10:30 a.m. with the CMD revealed the following: In the walk-in freezer there was an 80-ounce (oz) bag of blueberries with a label indicating that the bag was opened on [DATE] and a use by date of [DATE]. CDM reported that she thought that the facility could leave frozen items in the freezer up to six months. CDM confirmed that based on the label it indicated an expiration date of [DATE]. During interview on [DATE] at 1:05 p.m. the Director of Nursing (DON) reported that the facility does not have a policy specific to discarding foods by the expiration date. During an observation and interview with the DON and CDM on [DATE] at 4:52 p.m. in the servery kitchen the following was revealed: 1. In the cooler there was a container with cream cheese that was not labeled or dated. 2. In the refrigerator there were two containers of thickened liquid apple juice (use by [DATE]) and two cartons of thickened water (used by [DATE]). 3. In the refrigerator there was a cup of tea in a cup that did not have a lid on it and was not dated. CDM reported that the refrigerator should be checked daily, by dietary staff, for expired items and items should be discarded once found. CDM reported that she was not sure if items could be used beyond the best by date. She reported that the date was the best buy date but it didn't say expired. She went on to say that she would have to follow up because she is not sure how they do things here. It was then questioned how the expiration date is identified if the use by or best by date is not used. The DON reported that her expectation is that items are used by the best by and used by dates. There was a sign on the refrigerator door that stated items in the refrigerator should be labeled, dated, and have a use by date prior to placing in the refrigerator. On [DATE] at 6:20 p.m. temperature checks for dinner meal check began with the CDM and Dietary AA after the first cart of trays had been sent for delivery. The following was revealed: 1. Chicken parmesan was 123 degrees Fahrenheit (F). It was reheated in two batches to 178 F and 181 F. 2. Beef patties were 103 F. They were reheated but not used. 3. Roast beef was 120 F with a final reheat of 184 F. 4. Marinara sauce was 120 F with a final reheat 170 F. During an interview with the CDM and Dietary AA on [DATE] at 6:32 p.m. it was revealed that items on the steam table should be holding at 125 F. Dietary AA then said it should be holding 145 F and if reheated should be reheated to 165 F. It was discovered that the second holding well on the steam table was not getting hot enough. The light was not illuminated to indicate that it was on, but they reported the light does not work but it should still get hot. On [DATE] at 7:23 a.m. the Assistant DM confirmed the seven cartons of heavy whipping cream in the walk-in cooler with a use by date of ,d+[DATE]. Assistant DM reported that he was responsible for checking for expired items and he missed those items. He also confirmed that the use by and best by dates are used as the expiration dates and items should not be used beyond those dates. Assistant stated, You got me again and then discarded the items. On [DATE] at 7:30 a.m. the CDM confirmed the container for the sugar and corn meal with lids that were not tightly fitting (gap) and also confirmed build up on the containers. A final kitchen tour and interviews were conducted on [DATE] at 9:17 a.m. with the CMD and Dietary staff with the following being confirmed: 1. The food buildup and spills on wall and door near trashcan were confirmed. Cook CC reported this area is supposed to wiped down daily. She reported that she did not work on last night. A wet paper towel was used on the door and the staining was removed in the area that was wiped. 2. Food splatter in microwave. 3. There was flaking paint on pipes at the top entry into the kitchen. 4.There was build up on light covers in kitchen. 5. There was buildup of grease and oil on the back of the stove in the kitchen. Cook BB, Cook CC, and Cook DD all reported that everyone should be cleaning daily as spills happen. However, each Wednesday someone was supposed to provide a deep cleaning of the kitchen. CDM also confirmed that everyone should be responsible for cleaning, but she is still learning how things are done in this facility and she has only been in her role for two weeks. It was reported that they would have to notify Maintenance about the grease/oil on the back of the stove, flaking paint, and light covers as those are areas that Maintenance would have to address.

Based on staff interviews, record review, and facility policy titled Reporting and Investigating Abuse, the facility failed to reported abuse timely related to a resident-to-resident incident (R#6 and R#290) for one of four facility reported incidents reviewed. Findings include: Review of abuse police titled, Reporting and Investigating Abuse (2020), revealed: Procedural Guidelines - Reporting d. Once a complaint or situation is identified involving alleged mistreatment, neglect, or abuse, including injuries of unknown source and/or misappropriation of patient property and is reported to the Administrator, the incident will be immediately reported (within 2 hours) to the State. R#6 admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R#290 admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Nurse's Note dated 1/5/2022 revealed the Medical Doctor (MD) was notified of an incident from the previous evening in which R#290 entered another male resident's room and made unwanted sexual advances. The family was notified of MD's instructions for a psych evaluation of R#290 and made the decision to discharge R#290 from the facility. Review of Facility Report dated 1/5/2022 indicated an abuse incident between two residents took place on 1/4/2022 at 6:30 p.m. which consisted of verbal and physical aggression but no injuries. Interview and observation on 2/8/2022 at 2:42 p.m. revealed R#6 was sitting in wheelchair in his room. R#6 does not recall the incident with R#290. Interview on 2/10/2022 at 6:55 a.m. with Licensed Practical Nurse (LPN) CC who reported that she remembered the incident between R#6 and R#290. She explained that the incident took place just before shift change and R#6 was visibly upset about the situation with R#290. She reported that the Administrator was notified of the incident shortly after it happened. She further reported that hourly rounds were done to assure that R#6 was ok and that R#290 did not go back to the room to bother R#6. She further reported that R#290 discharged from the facility the day after the incident. During an interview on 2/10/2022 at 9:19 a.m. with the Administrator it was reported that if there is an allegation of abuse that resulted with an injury abuse is reported within two hours but if there is no injury it is reported within 24 hours. During an interview on 2/10/2022 at 3:30 p.m. with the Interim Director of Nursing (DON), Registered Nurse (RN) DD, and Consultant all reported that if there is no injury related to abuse the report is submitted within 24 hours. Interview on 2/10/2022 at 5 p.m. with RN DD who revealed that the facility has always sent any reports of abuse within 24 hours and had they realized it needed to be sent in within two hours it would have been done.

Based on record review and staff interview the facility failed to maintain complete, detailed and timely records for residents receiving hospice care. This affected one (1) resident, #25, from a sample of twenty-two (22) residents. Findings include: A review of the clinical record of resident #25 revealed that she was receiving hospice care. A review of the contract between the facility and the hospice provider revealed that the hospice provider was responsible for preparing and maintaining complete and detailed clinical records for each resident receiving services. The agreement further stipulated that the hospice service clinical records were to provide complete, prompt and accurate documentation of services provided to, and events concerning, each resident receiving hospice care. Further record review revealed that the last documented visit made to the facility by a hospice service Registered Nurse (RN) was on 01/18/12. There were no documentation in the clinical record of visits made to the facility by a hospice service chaplain, social worker, nursing aide or volunteer. A review of the resident's Care Plan Conference Sheet dated 2/29/12 revealed that no representative for the hospice provider had attended any of the resident's recent care plan meeting. Further record review revealed that there were no interventions in the resident's care plan that were delineated between the facility and the hospice staff as stipulated by the agreement between the facility and the hospice provider. These findings were confirmed in an interview with the facility's Director of Nursing (DON) and the hospice service Director in an interview on 4/10/12 at 4:00 p.m.

Based on observation and staff interview, it was determined that the facility failed to maintain the proper amount of sanitizer in the low temperature dishwasher and failed to promote staff hygiene while working in the food preparation area. Findings include: 1. During observation of the use of the low temperature dishwasher on 9/29/10 at 9:00 a.m., the sanitizer did not register on the chemical strip after the dietary aide attempted to check the amount of sanitizer in the rinse cycle. The food service supervisor came into the dishwasher area and called for another dietary staff member to come check the sanitizer instructing them to try pumping the primer button located on the side of the machine. Three (3) more attempts to check the sanitizer level revealed that the chemical strip did not register, indicating that the sanitizer chemical was not entering the dishwashing machine. A review of the facility's dishwasher log at that time, revealed that the sanitizer and temperatures had already been logged in as being within the acceptable ranges although it was only 9:00 a.m. 2. During observations of the dietary department on 9/29/10 at 9:00 a.m. and 11:30 a.m. the food service supervisor was seen wearing a hair net that failed to completely restrained the front of his/her hair while he/she was working in the dietary department.

Based on record review, observations and resident and staff interviews, it was determined that the facility failed to ensure that one (1) resident ("A") was not served his/her food dislikes from a total sample of thirteen (13) residents. Findings include: Resident "A" had a physician's orders [REDACTED]. However, on 9/28/10 at 1:05 p.m., staff served the resident mashed potatoes with gravy for lunch. The resident consumed only a few bites of the mashed potatoes with gravy. On 9/29/10 at 12:45 p.m., staff served the resident chopped beef tips with gravy for lunch. The resident consumed only a few bites of the chopped beef tips with gravy. Interview on 9/29/10 at 12:45 p.m. with Resident "A" revealed that he/she did not like gravy and had told staff on several occasions that he/she did not like gravy but the staff continued to serve him/her food items with gravy. Interview on 9/30/10 at 10:10 a.m. with the dietary manager revealed that resident "A" had a physician's orders [REDACTED]. She acknowledged that the resident chose his/her food items for each meal from the "Select Menu" card and that dietary staff served the resident those foods that he/she had chosen. Continued interview revealed that mechanical soft meats were often served with a sauce or gravy to make them more palatable and that the "Select Menu" card did not document the resident's likes and dislikes. Review of the dietary card for resident "A" revealed that under special request, the words no gravy are written and under the dislikes column, the word gravy is written.

Based on observation and staff interview, it was determined that the facility failed to thoroughly clean one (1) resident (#6) from a sample of thirteen (1)3 residents. Findings include: Resident #6 was coded on the 9/19/10 Initial Minimum Data Set (MDS) as requiring total assistance with toileting. On 9/28/10, the resident left for a doctor's appointment and did not return until 2:00 p.m. The resident was observed on 9/28/10 at 2:00 p.m. lying in the bed wearing pants that were visibly wet. A urine odor was present in the room. Certified Nursing Assistant (CNA) "RR" was observed walking out the resident's bathroom with a wet towel and stated that she was preparing to give the resident incontinence care. After the CNA removed the resident's wet pants and saturated brief, a strong urine smell could be detected. During the observation of incontinence care, CNA "RR" sprayed the resident's perineal area with peri-wash solution and cleaned the area with one end of the wet towel, refolding areas on the towel between each wipe. The CNA then dried the resident with the other end of the towel. The resident was assisted to his/her right side and the CNA then wiped the resident's buttocks area with the wet end of the same towel failing to spray peri-wash on the area before wiping the buttocks. The CNA dried the resident's buttocks with the other end of the towel and then applied a clean brief to the resident.