Martha Franks Baptist Retirement Center

Based on observations, staff interviews, and a review of facility policy, the facility failed to properly label and discard expired food items in the main kitchen (1 of 1). This failure to follow proper food storage protocols presents a potential risk to the health and safety of the 79 residents who consume food prepared in the facility's kitchen. Findings include:A review of the facility's policy, titled Food Storage with a Copyright date of 2017, revealed, All stock must be rotated with each new order received, and that rotating stock is essential to assure the freshness and highest quality of all foods. The policy requires that old stock is always used first (first-in - first out method) and that the person designated to put stock away must be supervised to ensure stock is rotated properly. The policy further states that food should be dated as it is placed on shelves if required by state regulation, and that high-risk, ready-to-eat, time/temperature control for safety foods must have visible date marking to indicate the date or day by which the food should be consumed, sold, or…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on review of the facility's policy, observations, and interviews, the facility failed to ensure the proper handling and transport of resident linens in a manner that prevents cross-contamination. This lapse in infection control practices poses a potential risk to resident health and safety by increasing the likelihood of infectious agents spreading.Findings include:Review of the facility's policy titled, Handling Soiled Linens: revised 08/20/2025 stated2. All used linen should be handled using standard precautions (i.e., gloves) and treated as potentially contaminated. Other protective equipment may be required. Examples of linen that may require special handling include, but are not limited to:a. Visibly soiled with blood or large amounts of body fluidb. Residents with contagious conditions such as chicken pox, herpes zoster, or other skin lesions.c. Residents with infectious drainage not contained by dressings or other supplies.d. Residents with infections transmitted by contact (e.g., MRSA, VRE, Clostrioides difficile).Review of facility policy titled Laundry Policy…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and facility policy review, the facility failed to ensure the floor in the kitchen was free of debris, staff appropriately wore a hair restraint, food items were labeled and dated, expired food items were discarded, and personal items were not stored in the nourishment room. These deficient practices had the potential to affect all residents who received food from the kitchen. Findings included: 1. A facility policy titled, Cleaning and Sanitation of Dining and Food Service Areas, with a copyright date of 2017 revealed, Policy: The nutrition and food services staff will maintain the cleanliness and sanitation of the dining and food services areas through compliance and a written, comprehensive cleaning schedule. In an observation of the second dry storage room on 07/29/2024 at 9:07 AM, there was one individual packet of a sugar substitute and one individual packet of mayonnaise on the floor. During a concurrent observation of the freezer on 07/29/2024 at 9:12 AM, there was a dirty wet towel on the floor at the entrance of the freezer. The Director of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, record review, review of the Resident Assessment Instrument (RAI) Manual, and facility policy review, the facility failed to ensure a Minimum Data Set (MDS) assessment accurately reflected the status for 1 (Resident (R)31) of 22 sampled residents. Specifically, the facility failed to ensure R31's MDS accurately reflected the resident's fall status. Findings included: A facility policy titled, Resident Assessments, revised 03/2022, revealed 1. The resident assessment coordinator is responsible for ensuring that the interdisciplinary team conducts timely and appropriate resident assessments and reviews according to the following requirements: a. OBRA required assessments - conducted for all residents in the facility. The Centers for Medicare & Medicaid Services Long-Term Care Facility Resident Assessment Instrument [RAI] 3.0 User's Manual, dated 10/2023, indicated that according to 2. If this is not the first assessment, the review period is from the day after the ARD [Assessment Reference Date] of the last MDS assessment to the ARD of the current…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview, record review, and facility policy review, the facility failed to develop a care plan to address the wandering behavior of 1 (Resident (R)172) of 22 sampled residents. Finding included: A facility policy titled Care Plans, Comprehensive Person-Centered, revised 03/2022, revealed, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical psychosocial and functional needs is developed and implemented for each resident. A Resident Face Sheet revealed the facility admitted R172 on 03/27/24. According to the Resident Face Sheet, the resident had a medical history that included diagnoses of lack of coordination, muscle weakness, difficulty in walking, falls, Alzheimer's disease, and dementia. An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/02/24, revealed R172 had a Brief Interview for Mental Status (BIMS) score of 3, which indicated the resident had severe cognitive impairment. R172's Resident Progress Notes, dated 04/08/24 at 11:23 AM, revealed the resident often…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure nail care was provided to a dependent resident for 1 (Resident (R)26) of 2 residents reviewed for activities of daily living (ADL). Findings included: A facility policy titled, Fingernails/Toenails, Care of, revised 02/2018, revealed, 1. Nail care includes weekly cleaning and regular trimming as tolerated. The policy revealed, 1. Notify the supervisor if the resident refuses the care. A Resident Face Sheet indicated the facility admitted R26 on 05/21/2018. According to the Resident Face Sheet, the resident had a medical history that included diagnoses of Alzheimer's disease, diabetes mellitus, and dementia with behavioral disturbance. A quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/19/2024, revealed R26 had a Brief Interview for Mental Status (BIMS) score of 4, which indicated the resident had severe cognitive impairment. The MDS indicated the resident was dependent on staff for personal hygiene. R26's Care Plan included a problem statement…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, record review, document review, and facility policy review, the facility failed to ensure staff wore personal protective equipment (PPE) for 1 (Resident (R)27) of 5 sampled residents reviewed for infection control, who was on enhanced barrier precautions (EBP). Findings included: A facility policy titled, Enhanced Barrier Precautions with a revision date of 08/2022, indicated, 2. EBPs employ targeted gown and glove use during high contact resident care activities when contact precautions do not otherwise apply. a. Gloves and gown are applied prior to performing the high contact resident care activity (as opposed to before entering the room). The policy revealed 3. Examples of high-contact resident care activities requiring the use of gown and gloves for EBPs include: a. dressing; b. bathing/showering; c. transferring; d. providing hygiene; e. changing linens; f. changing brief or assisting with toileting; g. device care of use (central line, urinary catheter, feeding tube, tracheostomy/ventilator, etc. [et cetera, and other similar things]); and h.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on review of the facility policy, record review and interview, the facility failed to report an alleged violation within 24 hours for 1 of 4 residents reviewed (Resident (R)3. Findings include: Review of the facility policy titled, Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating states 3.b. Immediately is defined as within 24 hours of an allegation that does not involve abuse or result in serious bodily injury. Record review on 12/5/2023 at 10:30 AM revealed the facsimile stapled to the 24 Initial Report was dated 7/26/2023 at 1456 (2:56 PM). The Date/Time of the Reportable Incident was dated 7/24/2023 at 11:30 AM. Review of the progress note dated 7/24/2023 at 11:30 AM revealed discovery of R3 bleeding from her forehead and 911 was called. An interview was conducted with the Administrator on 12/5/2023 at 12:50 PM. She stated, There was a time lapse for the reporting of stitches. She said she was made aware the next morning and went ahead and reported it. She said the Director of Nurses didn ' t think it was a reportable for stitches. She said she…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, and review of the facility policy, the facility failed to ensure that the consulting pharmacist identified during the monthly medication regimen review all irregularities. Specifically, a resident had an order for an as needed (PRN) antipsychotic medication and there was no indication of a 14 day stop date or that the consulting pharmacist identified this issue for one resident (R)59 of 5 residents reviewed for unnecessary medications, resulting in the potential for adverse side effects from an unnecessary medication. Findings include: Review of R59's Face Sheet (undated) found in the Electronic Medical Record (EMR) under the Resident tab indicated R59 was admitted to the facility on [DATE] with diagnoses of dementia in other diseases classified elsewhere without behavioral disturbance and generalized anxiety disorder. Review of R59's Minimum Data Set Assessment (MDS) with an Assessment Reference Date (ARD) of 03/22/22 found in the EMR under the RAI tab revealed R59 did not…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review and review of the facility policy, the facility failed to ensure that the use of an PRN (as needed) psychoactive medications was not continued beyond the 14 days without documentation from the resident's physician the indication for continued use for one of five residents (R)59 reviewed for unnecessary medications, resulting in the potential for adverse side effects from an unnecessary medications. Findings include: Review of R59's Face Sheet (undated) located in the Electronic Medical Record (EMR) under the Resident tab indicated R59 was admitted to the facility on [DATE] with diagnoses of dementia in other diseases classified elsewhere without behavioral disturbance and generalized anxiety disorder. Review of R59's Minimum Data Set Assessment (MDS) with an Assessment Reference Date (ARD) of 03/22/22 located in the EMR under the RAI tab revealed R59, that a Brief Interview for Mental Status (BIMS) had not been completed, indicating the resident was severely…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.