The finding was one of 16 deficiencies cited during a complaint inspection conducted on September 18, 2025.
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All three had care plans explicitly specifying full-body mechanical lift transfers.
The inspection was triggered by a complaint.
The grilled cheeseburger, served on a bun, was room temperature.
The resident, identified in inspection records as Resident 4, has lived at the facility since September 2018.
The incident involved Resident #205, a person identified in facility records as someone at risk for wandering.
Inspectors classified it as an isolated deficiency with no documented actual harm, but with the potential for more than minimal harm.
Nowhere in the policy did it say staff needed to clean their hands between removing soiled gloves and putting on clean ones.
They are almost entirely preventable with attentive repositioning, proper support surfaces, and consistent wound care.
Feeding tube placement is not a minor procedure.
You can't." CNA 2 was not available for interview during the inspection.
The aide, identified in inspection records only as CNA 1, was assigned to the resident from 7 a.m.