Market Square Health Care Center, LLC

Inspectors wroteBased on observations, record reviews, and interviews, the facility failed to promote care for residents in a manner that maintains each resident's dignity for 2 of 2 sampled residents (Residents #41, #51) on 2 of 4 days of survey (5/11/26, 5/12/26).

Inspectors wroteBased on observations and interviews, the facility failed to adequately provide housekeeping and maintenance services necessary to maintain the building in a sanitary, orderly, and comfortable environment on 3 of 3 units ([NAME] East, [NAME] and Tuttle) and the laundry room for 1 of 1 facility tour.

Inspectors wroteBased on record reviews and interviews the facility failed to provide written transfer/discharge and bed hold notices to include cost of care, which included appeals rights to 4 of 4 residents reviewed for discharge (Resident #1, #9, #38 & #77).

Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure a resident's comprehensive care plan was developed and implemented to reflect the current needs of the resident for 5 of 18 residents reviewed for care planning (Residents #17, #38, #25, #61, #85).

Inspectors wroteBased on record review, policy review and interviews, the facility failed to ensure lifesaving medical equipment was restocked and readily available for use in an emergency for 2 of 2 emergency (crash) carts observed ([NAME] East and Tuttle Units).

Inspectors wroteBased on observations, interviews, record review, facility policy, and a review of Safety Data Sheets (SDS), the facility failed to ensure that the resident's environment was free of accident hazards by failing to ensure that a patient lift had working safety clips and failing to ensure that chemicals were properly secured for 2 of 2 observations for 2 of 4 days of survey (5/11/26 and 5/12/26). Additionally, the facility failed to ensure that a resident's motorized wheelchair safety screen was completed for 1 of 3 residents reviewed for accidents (Resident #61).

Inspectors wroteBased on observations and interviews, the facility failed to provide a sanitary environment to ensure that respiratory equipment was clean to help prevent the development and transmission of disease and infection related to oxygen tubing for 1 of 3 residents reviewed for respiratory care (Resident #11).

Inspectors wroteBased on record reviews and interviews, the facility failed to ensure that two people who are authorized to administer medications signed the Shift Count page indicating that they counted all controlled substances at the change of shift for 2 of 3 units reviewed for medication storage (Tuttle and Andrew's Went Unit's).

Inspectors wroteBased on facility policy, record review, observations, and interviews, the facility failed to adequately ensure medications and biologics were stored at appropriate temperatures in 3 of 3 refrigerators observed for 3 of 3 months of medication refrigerator logs reviewed. Additionally, the facility failed to ensure treatments were stored properly for 2 of 4 days of survey. (5/11/26 and 5/12/26)

Inspectors wroteBased on observations and interview, the facility failed to ensure the kitchen was maintained in a clean and sanitary manner for a food mixer, food storage bins, the ceiling, the hood system, a door, and floors; failed to ensure foods were sealed, labeled and/or dated on kitchen carts and in a walk-in freezer for 2 of 2 kitchen/kitchenette tours for 1of 4 days of survey (5/11/26); and failed to ensure Daily High-Temp Ware Wash temperatures, the Freezer and Refrigerator Temperatures, and Sink/Bucket Sanitizer and 3-Bay parts per million(PPM) were monitored/documented for 1 of 4 days of survey. (5/12/26) Additionally, the facility failed to serve food in in sanitary manor for 1 of 4 days of survey. (5/11/26)

Inspectors wroteBased on observations, record review, and interviews, the facility's Quality Assurance Committee failed to ensure that the Plan of Correction for identified deficiencies from the Annual Long Term Care Survey Process for Federal Recertification, dated 5/14/26, were effective. The Federal citations F584 and F812 were cited again for the same concerns during the follow-up survey completed on 7/7/26. At the annual recertification survey completed on 5/14/26, deficiencies F584 and F812 were cited. During the follow up survey on 7/7/26, it was determined that F584 and F812 would be recited for the same concerns: 1. F584: Safe/clean/comfortable/homelike environment: Observation of laundry room on 7/7/26 revealed the surface of the cement floor was worn off and untreated creating an uncleanable surface. There were 15 (fifteen) cracked/broken and/or missing floor tiles. [...]

Inspectors wroteBased on observations, interviews, record review, and facility policy, the facility failed to maintain an Infection Control Program designed to provide a sanitary environment to help prevent the development and transmission of disease and infection related to the use of Personal Protective Equipment (PPE) while providing care for a resident on Enhanced Barrier Precautions (EBP), sanitizing glucometers, linen handling, hand hygiene during resident care, and applying transmission based precaution for 3 of 4 days of survey (5/11/26, 5/12/26, 5/13/26). Additionally, the facility failed to conduct an annual review of its Infection Prevention and Control Program (IPCP).

Inspectors wroteBased on interviews and facility policy the facility implements, and maintain an effective training program for all staff. Appropriately trained staff can improve resident safety, create a more person-centered environment, and reduce the number of adverse events or other resident complications. This has the potential to affect all three units.

Inspectors wroteBased on observations and interviews, the facility failed to ensure a resident's call bell was within reach for 2 of 2 sampled residents (Residents #5, #51) for 2 of 4 days of survey (5/11/26, 5/12/26).

Inspectors wroteBased on observations and interviews, the facility failed to ensure the confidentiality of protected health information for 1 of 70 residents during 1 of 4 days of survey. (Resident #38)

Inspectors wroteBased on record review, interviews, and facility policy, the facility failed to thoroughly investigate a resident's injury of unknown origin for 1 of 3 facility-reported incidents (Resident #27).

Inspectors wroteBased on record review and interview, the facility failed to ensure the Minimum Data Set (MDS) Version 3.0 Assessments were accurately coded in the area of therapy services for 1 of 20 sampled residents (Resident #38).

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure that a care plan was developed in the area of quality of care and accurate for opioid therapy for 1 of 1 resident reviewed. (#77)

Inspectors wroteBased on record reviews and interviews, the facility failed to ensure the clinical record was accurate and complete for 1 of 2 residents reviewed for therapy services (Resident #85) and 1 of 2 residents reviewed for Activities of Daily Living (ADL) (Resident #17).

Inspectors wroteBased on Certified Nursing Assistant (CNA) employee education review and interview, the facility failed to monitor and ensure that the CNA attended the required 12 hours of annual in-service education training for 1 of 5 randomly selected CNAs employed greater than 1 year. (CNA #1)

Inspectors wroteBased on record review and interview, the facility failed to maintain an Infection Control Program designed to help prevent the development and transmission of disease and infection relating to Legionella and failed to implement the elements of the Legionella Water Management Program. This has the potential to affect all 68 residents.

Inspectors wroteBased on observations and interviews, the facility failed to adequately provide housekeeping and maintenance services necessary to maintain the building in a sanitary, orderly, and comfortable environment on 3 of 3 units ([NAME] East, [NAME] and Tuttle) for 1 of 1 facility tour.

Inspectors wroteBased on record review and interview, the facility failed to issue a bed hold notice which included the daily bed hold cost, to a resident, known family member and/or legal representative for 3 of 3 sampled residents who had been transferred to the hospital (Residents #7, #66, and #69).

Inspectors wrote2. Resident #67 was recently admitted to the facility. A review of the nursing assessments, dated 2/11/25 for Resident Smoking Screen and a Resident Smoking Contract state he/she can smoke unsupervised. As of 3/3/25 the residents' care plan lacked interventions and goals relating to smoking. On 3/3/25 at 4:01 p.m., the above was discussed with the Quality Improvement Specialists Based on interviews, record review, and facility policy, the facility failed to ensure a baseline care plan was developed and implemented within 48 hours. That included the instructions needed to provide minimum healthcare information necessary to care for 3 of 25 care plans reviewed (Resident's (R)4, R55, and R67).

Inspectors wroteBased on record reviews and interviews, the facility failed to ensure that two people who are authorized to administer medications signed the Shift Count page indicating that they counted all controlled substances at the change of shift for 2 of 2 units reviewed for medication storage (East and [NAME] Units).

Inspectors wroteBased on observations and interviews, the facility failed to ensure the kitchen was maintained in a clean and sanitary manner for floors, the food disposal unit, a wall mounted fan, and a plunger. Additionally, the facility failed to ensure foods were sealed, labeled, dated and/or discarded if past use by date in a reach-in freezer, in a walk-in refrigerator, a unit kitchenette refrigerator and in a dry storage room for 2 of 2 kitchen/kitchenette tours for 1 of 1 day of survey (3/3/25).

Inspectors wroteBased on record review and interviews, the facility failed to ensure that a clinical record contained complete and accurate documentation for 2 of 2 residents reviewed for smoking (Resident's #55 #67), and for 2 of 5 residents reviewed for medication review (Resident #45 and #55).

Inspectors wroteBased on interviews and record review, the facility failed to ensure accommodations were made for a resident to include the facility's bathing schedule and resident preferences for 1 of 3 residents reviewed for activities of daily living (Resident #7).

Inspectors wroteBased on record reviews, interviews, and facility policy the facility failed to update/implement goals and interventions for diuretic and anticoagulant medication use for 1 of 1 resident reviewed for (Resident #11).

Inspectors wroteBased on clinical record review and interview, the facility failed to ensure physician orders were followed for 1 of 2 sampled residents for (Resident #67).

Inspectors wroteBased on observations, record review, and interviews, the facility failed to provide a sanitary environment to help prevent the development and transmission of disease and infection related to respiratory care for 1 of 1 resident reviewed for respiratory care (Resident #29).

Inspectors wroteBased on record review and interviews, the facility failed to ensure an as needed (prn) psychotropic medication met the required 14-day limit for 2 of 6 residents reviewed for psychotropic medications (Resident #4 and #67).

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to ensure medications including treatments were stored properly for 2 of 3 days of survey (3/3/25 and 3/4/25). Additionally, the facility failed to obtain physician orders for medications located at a resident's bedside, for 1 of 1 sampled resident (Resident #322).

Inspectors wroteBased on record review, interviews, and facility policy, the facility failed to ensure a resident's care plan was updated to reflect the resident's current care needs in the area of falls for 1of 3 residents reviewed (Resident #4).

Inspectors wroteBased on record review and interviews, the facility failed to ensure that clinical records were complete and contained accurate information for 2 of 3 residents reviewed. (Residents #4 and #5).

Inspectors wroteBased on observations, interviews, and facility policy, the facility failed to maintain an Infection Control Program designed to help prevent the development of infection for 1 of 3 sampled residents. (Resident 3)

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure that the facility's laundry equipment was maintained, according to manufacturer's instructions, and operated to ensure proper cleaning and disinfecting of linens for 1 of 1 day of survey(11/5/24). This has the potential to affect all residents.

Inspectors wroteBased on observations, interview, the facility's Daily High-Temp Ware Wash checklist directions, the facility's Refrigerator/Freezer Temperature Logs and the facility's Sink/Bucket Sanitizer Log directions, the facility failed to ensure the kitchen was maintained in a clean and sanitary manner for wall mounted air conditioning units, the floors, a plunger, a dish air dry machine, a grease trap, a wall vent, a ceiling light and a walk-in freezer. Additionally, the facility failed to ensure the walk-in refrigerator/freezer temperatures were monitored; failed to ensure the dishwasher temperatures were monitored; failed to ensure the sink/buckets sanitizers were monitored and failed to ensure food was properly labeled and dated in the walk-in freezer for 1 of 1 kitchen tour for 1 of 1 day of survey (10/7/24).

Inspectors wroteBased on observations and interviews, the facility failed to ensure that the small and large steam tables were maintained in good repair and in safe operating condition for 2 of 2 kitchen tours (10/7/24).

Inspectors wroteBased on observations and interviews, the facility failed to ensure 2 of 2 dietary food service workers had the appropriate competencies and were adequately trained around knowing the proper temperatures for foods served to residents. This has the potential to affect all 45 residents in the facility.

Inspectors wroteBased on interviews, record review and facility policy, the facility failed to ensure care plans were updated/implemented for side rails for 1 of 1 Resident (#12), smoking for 1 of 1 Resident's (#35) and in the area of dental for 1 of 1 Resident (#41) of 17 residents reviewed for comprehensive care plans.

Inspectors wroteBased on observation and interview, the facility failed to adequately date and properly dispose of open biologicals according to manufacturer specifications and expired medications in 2 of 3 units, [NAME] East and [NAME] West.

Inspectors wroteBased on observations and interview, the facility failed to maintain a clean/sanitary environment on 2 or 3 wings observed ([NAME] East and [NAME] West) for 3 of 3 days of survey.

Inspectors wroteBased on record review and interview, the facility failed to ensure a plan of care was updated in the care area of Nutrition for 1 of 17 resident care plans reviewed. (#2)

Inspectors wroteBased on interviews and record review the facility failed to follow physician order for wound evaluation and failed to follow the facilities Skin Management policy for 1 of 1 Resident reviewed for pressure ulcer management. (#20)

Inspectors wroteBased on clinical record review and interview, the facility failed to ensure that the Minimum Data Sets, version 3.0 (MDS) was accurately coded for 1 of 1 resident reviewed for smoking (Resident #35) and 1 of 1 resident reviewed for restraints. (Resident #12).

Inspectors wroteBased on interview and record review, the facility failed to implement a training/education program which includes dementia training by failing to ensure that 2 of 5 staff reviewed for in-service training completed the required training. (Employee #4 and #5). On 8/2/22 during a review of the facility staff education records the following was noted: Employee #4 was hired on 7/15/22 and as of 8/2/22 his record lacks evidence of dementia training. Employee #5 was hired on 7/12/22 and as of 8/2/22 her record lacks evidence of dementia training. On 8/2/22 at approximately 2:55 p.m. in an interview with the Assistant Director of Nursing Services, she confirmed that employee #4 and employee #5 did not receive dementia training since being hired. She stated that both employees work with dementia Residents and that both employees are scheduled to have the dementia training this month.