Community Memorial Continuing Care Center

Inspectors wroteBased on observation, interview and record review the facility failed to ensure food items stored in the refrigerators were clearly labeled and dated to support safe storage practices when:Multiple perishable food items had unclear or incomplete date stamps, preventing staff from determining the appropriate use-by/discard timeframe. A perishable sandwich containing meat and cheese was stored without a label identifying the contents/type of the sandwich. These failures had the potential for residents to consume expired or contaminated food and increase the risk of allergen exposure due to unidentified ingredients, placing residents at risk for foodborne illness and allergic reactions. During an observation and concurrent interview on 1/13/25 at 9:37 a.m. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a physicians order was obtained for urinary catheter change and care for one of 18 sampled residents (Resident 1). This failure resulted in Resident 1 receiving care without a physician's order. During a review of Resident 1's Face Sheet (FS), dated 1/15/26, the FS indicated, Resident 1 was admitted to the facility on [DATE] with a diagnosis of encephalopathy (any type of disorder, disease or damage that affects your brain's function or structure). During a concurrent interview and record review on 1/15/26 at 3 p.m. with the Minimum Data Set Coordinator (MDSC), Resident 1's urethral catheter assessments and nursing progress notes were reviewed. The review indicated, the urinary catheter was changed on 12/22/25 and 1/10/26, and the urinary catheter was reinserted on 1/14/26. [...]

Inspectors wroteBased on interview and record review, the facility failed to follow its Policy and Protocol (P&P) for 1 of 18 sampled residents (Resident 18) by not ensuring physician review and documented response to the consultant pharmacist's Medication Regimen Review (MRR - a comprehensive, mandatory evaluation of a resident's medication regimen performed by a licensed pharmacist to promote positive outcomes, minimize adverse consequences, and ensure safety) for lorazepam (anti-anxiety medication) regimen when:This failure had the potential to result in Resident 18's continued use of an unnecessary drug (a medication given without a clear ongoing need or proper monitoring and/or adverse medication-related outcomes (harmful side effects)) without appropriate physician oversight and clinical rationale (a documented medical reason for the decision). [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to properly label food items for their received, opened and expiration dates before storage. This failure had the potential to cause food borne illnesses to the residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure a Certified Nursing Assistants (CNA 1) certification was valid prior to their start of and duration of employment at the facility. These failures had the potential to negatively impact patient care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the privacy of protected health information (PHI-is any information in the medical record or designated record set that can be used to identify an individual and that was created, used, or disclosed while providing a health care service such as diagnosis or treatment.) for twenty two of sixty three residents residing in the facility. This facility failure resulted in twenty two residents protected health information potenitally being compromised.

Inspectors wroteBased on interview and record review, the facility failed to ensure staff safeguarded the personal property of one of eighteen sampled residents (Resident 56). When a topical gel cream called Liniment Gel (a topical gel used to temporary relief of muscle or joint pain) that was mailed to the resident in the facility was taken away by a facility staff member and never replaced nor reimbursed. This failure resulted in a resident not having the right to retain and use a personal possession in the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure a follow up/new Preadmission Screening and Resident review (PASRR-mental disability assessment) for Level 1 was done for 1 of 18 residents (Resident 30). This failure had the potential to result in Resident not being adequately assessed to receive recommended care and treatment.

Inspectors wroteBased on interview and record review the facility failed to initiate a Care Plan (a part of the nursing process which outlines the plan of action that will be implemented during a patient's medical care) for two of 18 sampled residents (Resident 59 and Resident 163) when: 1. Care plans for two antidepressants medications were not initiated for Resident 163 and, 2. A care plan for psychotropics was not initiated for resident 59. These facility failures have the potential to prevent residents from recieving individualized care and services.

Inspectors wroteBased on interview and record review of facility policy and procedures, the facility failed to update and revise a fall care plan for one of 18 sampled residents (Resident 169) after a fall incidence. This facility failure had the potential for new interventions and new fall precations to not be implemented which could potentially prevent Resident 169 form future falls.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure restorative nursing services (RNA) were provided to two of eighteen sampled residents (Resident 57, Resident 59). This facility failure resulted in Resident 57 and Resident 59 not receiving required services to ensure they maintain, improve, or restore muscle strength, balance, range of motion, and functional mobility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow appropriate dress code for food and nutrition services personnel in the kitchen failed to serve food in accordance with professional standards for food service safety. This failure has the potential for cross contamination of food (transfer of harmful bacteria to food when they are not handled properly).