John T Mather Memorial Hosp T C U

Inspectors wroteBased on observations, record review, and interviews conducted during the Recertification survey initiated on 5/21/2025 and completed on 5/23/2025, the facility did not follow proper sanitation practices to prevent the outbreak of foodborne illness and did not store and prepare food in accordance with professional standards for food service safety. This was identified during the Kitchen Task. Specifically, during the kitchen observation on 5/21/2025: 1) Multiple undated, unlabeled, uncovered cooked food, and expired food items were observed in the walk-in refrigerators, walk-in freezer, and dry storage room. 2) Multiple dietary staff did not perform proper hygienic practices including hand washing and hair covering while handling food. 3) There was an unsanitary soiled reach-in refrigerator and a soiled meat slicer. The washed wet cooking pans were nesting on top of each other. [...]

Inspectors wroteBased on observation, record review, and interviews during the Recertification Survey initiated on 5/21/2025 and completed on 5/23/2025, the facility did not ensure that each resident had physician orders for the resident's immediate care at the time the resident was admitted to the facility. This was identified for two (#158 and Resident #151) of two residents reviewed for Limited Range of Motion. Specifically, 1) Resident #158 utilized a lumbar spine orthosis without a Physician's order, and 2) Resident #151 had a diagnosis of left distal radial (arm bone near the wrist) fracture and was wearing a sugar tong splint (a type of splint that stabilizes injuries of the forearm and wrist by preventing forearm rotation and wrist motion) and sling on the left arm. There was no Physician's Order for using the sugar tong splint and sling until 5/22/2025.

Inspectors wroteBased on observation, record review, and interviews during the Recertification Survey initiated on 5/21/2025 and completed on 5/23/2025 the facility did not ensure it developed and implemented a baseline care plan for each resident that included the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. This was identified for one (Resident #158) of two residents reviewed for Limited Range of Motion. Specifically, Resident #158 used a lumbar spinal orthotic device due to a lumbar vertebra (spine) fracture; however, the device was not included in the baseline care plan and there was no physician's order for the device. The finding is: [...]

Inspectors wroteBased on observations, record review, and interviews during the Recertification Survey initiated on 5/21/2025 and completed on 5/23/2025, the facility did not ensure that each resident who needs respiratory care is provided such care consistent with professional standards of practice and the comprehensive person-centered care plan. This was identified for one (Resident #154) of one resident reviewed for Respiratory Care. Specifically, during observation, an unlabeled nebulizer mask was not covered and was hung on the wall-mounted oxygen flowmeter with the oxygen tubing still connected to the nebulizer mask in Resident #154's room. The finding is: The facility's policy and procedure titled Equipment Processing and Circuit Change Intervals last revised in July 2021 documented that each resident's nebulizer setup will be discarded and replaced every seven days by Respiratory Therapists. [...]

Inspectors wroteBased on observations, record review, and interviews during the Recertification Survey initiated on 5/21/2025 and completed on 5/23/2025 the facility did not ensure it established and maintained an infection prevention and control program designed to help prevent the development and transmission of communicable diseases and infections. This was identified for one (Resident #158) of six residents observed during the medication pass. Specifically, during the medication administration observation for Resident #158, Registered Nurse #2 brought the medication cart into the resident's room for medication administration. Registered Nurse #2 then dropped an individual blister-packed medication (one pill in an individual blister pack) onto the floor. [...]

Inspectors wroteBased on record review and staff interviews during the Recertification Survey initiated on 5/21/2025 and completed on 5/23/2025, the facility did not ensure that it designated one or more individual(s) as the Infection Preventionist(s) (IP)(s) who are responsible for the facility's Infection Prevention Control Program (IPCP) and the Infection Preventionist must have completed specialized training in infection prevention and control beyond initial professional training or education prior to assuming the role. Specifically, the facility's designated Infection Preventionist did not have documented evidence of specialized training in infection prevention and control beyond the initial professional training or education prior to assuming the role. Finding is: [...]

Inspectors wroteBased on record review and interviews during the Recertification Survey initiated on 5/21/2025 and completed on 5/23/2025, the facility did not ensure that the Infection Preventionist was a member of the facility's Quality Assurance & Performance Improvement (QAPI) and Quality Assessment & Assurance (QAA) committee and reported to the committee on the Infection Prevention and Control Program regularly. Specifically, the Infection Preventionist did not participate in the Quality Assurance & Performance Improvement meetings held from 8/5/2024 through 4/21/2025. The finding is: The facility's policy titled Quality Management and Patient Safety, dated 1/1/2025, documented that the facility will report outcomes quarterly in the Interdisciplinary Quality Assurance and Performance Improvement (QAPI) meetings. [...]

Inspectors wroteBased on observations, record review, and interviews conducted during a Recertification Survey initiated on 6/17/2024 and completed on 6/20/2024, the facility did not ensure that food was stored, prepared, distributed, and served in accordance with professional standards for food service safety. This was identified during the Kitchen observation conducted on 6/17/2024. Specifically, the walk-in refrigerator for produce and dairy was observed holding a rack of eight trays of cooked chicken breast and three pans of gravy sauce. The trays of cooked chicken breast were uncovered and undated and the gravy sauce was unlabeled and undated. A rack containing uncooked and undated bacon strips was observed. The bacon strips were taken out of their original package and prepped onto 15 baking sheets. [...]

Inspectors wroteBased on record review and interviews conducted during a Recertification Survey initiated on 6/17/2024 and completed on 6/20/2024, the facility did not ensure that their policy regarding the use and storage of foods brought to residents by family and other visitors included to ensure facility staff assists the resident in accessing and consuming the food if the resident is not able to do so on their own. Specifically, the facility policy did not include guidance to facility staff regarding assisting the resident in accessing, handling (reheating), and consuming the food brought in from outside by the family members and other visitors if the resident is not able to do so on their own. The finding is: [...]

Inspectors wroteBased on observation, record review, and staff interviews during the Recertification Survey, initiated on 6/17/2024 and completed on 6/20/2024, the facility did not ensure it maintained an infection prevention and control program designed to help prevent the development and transmission of communicable diseases and infections for one (Resident #58) of seven resident observed during the medication administration. Specifically, Resident #58 had a physician's order for a tuberculin skin test (a screening diagnostic test for Tuberculosis). When Registered Nurse #1 offered the test to the resident on 6/18/2024, the resident refused. There was no documented evidence that Registered Nurse #1 reported the refusal to the Physician. The finding is: [...]

Inspectors wroteBased on observation, record review, and staff interviews during the Recertification Survey initiated on 10/3/2022 and completed on 10/5/2022, the facility did not ensure proper sanitation practices were maintained in the main kitchen area to prevent the outbreak of foodborne illness. Specifically, during the initial tour of the main Hospital kitchen, the light fixtures near the kitchen exhaust fan were observed with a buildup of grease and dirt. The finding is: During the initial tour of the main Hospital kitchen area on 10/03/2022 at 11:39 AM, three light fixtures were observed with a buildup of grease and dirt near the kitchen exhaust fan. The Food Service Director (FSD) was interviewed on 10/3/2022 at 11:40 AM and stated the fixtures should not have a build-up of grease and dust and will be cleaned promptly. The FSD stated that the exhaust liner is cleaned every 2 months. [...]

Inspectors wroteBased on record review and staff interviews during the Recertification Survey initiated on 10/3/2022 and completed on 10/5/2022, the facility did not ensure that a copy of the notice of transfer or discharge was sent to the Office of the State Long-Term Care Ombudsman. This was identified for one (Resident #5) of one residents reviewed for hospitalization. Specifically, Resident #5 was transferred to the hospital on 8/22/2022. The facility did not notify the Office of the State Long-Term Care Ombudsman office of Resident #5's facility-initiated transfer and discharge to the hospital. The finding is: The facility policy dated 7/11/2022, titled Patient Discharge, did not include guidance related to notifying the Office of the State Long-Term Care Ombudsman in writing when the facility initiates a resident transfer or discharge. [...]