Matthews Health & Rehab Center

Inspectors wroteBased on record review and interviews with the Power of Attorney (POA), Medical Director, and staff, the facility failed to ensure a resident's advance directive information was entered throughout the medical record for 1 of 3 residents reviewed for advance directives (Resident #106).

Inspectors wroteBased on record review and interviews with staff, the Nurse Practitioner (NP), and the Medical Director, the facility failed to notify the physician/NP when ordered laboratory services could not be obtained for 1 of 3 residents reviewed (Resident #1).

Inspectors wroteBased on record review, observations, and staff, Health Department Nurse, and Physician interviews, the facility failed to implement the facility's infection control policy and procedures in accordance with current Centers for Disease Control and Prevention (CDC) guidance. The facility had been in outbreak status since 1/18/25 when 2 staff members tested positive and only residents and staff with COVID symptoms and staff that requested were tested for COVID. The facility failed to initiate contact tracing COVID testing for staff and residents on 1/18/25 after 2 staff members tested positive for COVID and failed to initiate broad-based approach COVID testing when a resident on the 200 hall and the 400-hall tested positive for COVID. No contact tracing or broad-based COVID testing was initiated until after surveyor intervention on 2/4/25. [...]

Inspectors wroteBased on record review, and staff and resident interviews, the facility failed to provide resolution of Resident Council Meeting grievances for 6 of 6 Resident Council Meetings (08/27/24, 09/24/24, 10/23/24, 11/05/24, 11/20/24, and 12/30/24). The Resident Council had repeated concerns regarding call lights not being answered and snacks not being provided.

Inspectors wroteBased on observations, record review, staff and Physician interviews, the facility failed to maintain wound vac (negative pressure wound therapy to help heal wounds) treatment as ordered and failed to follow treatment orders for when the wound vac malfunctioned or was broken for stage 4 sacral pressure ulcer for 1 of 3 residents reviewed for pressure ulcer (Resident #318).

Inspectors wroteBased on observation, record review, and staff and physician interviews, the facility failed to secure the indwelling urinary catheter to reduce tension for 1 of 2 residents (Resident #3) reviewed for urinary catheter.

Inspectors wroteBased on resident and staff interviews the facility failed to have systems in place for providing evening snacks to residents for 2 of 3 halls (100 hall and 400 hall). The deficient practice had the potential to affect residents requesting an evening snack.

Inspectors wroteBased on record review and staff interviews, the facility failed to provide Registered Nurse (RN) coverage for 8 consecutive hours for 2 of 30 days reviewed for staffing (4/20/24 and 4/21/24).

Inspectors wroteBased on record review, staff and Ombudsman interviews, the facility failed to notify the resident and his family member in writing of a transfer to the hospital for 1 of 3 residents reviewed for hospitalization (Resident #73) and failed to notify the Ombudsman each month of facility transfers and discharges for 3 of 3 months (November 2024, December 2024, and January 2025).

Inspectors wroteBased on record review, staff and Ombudsman interviews, the facility failed to provide a bed hold notice for 1 of 3 residents reviewed for hospitalization (Resident #73).

Inspectors wroteBased on record reviews, resident, staff, physician and family interviews, the facility failed to protect a resident's (Resident #1) rights to be free from physical abuse when Resident #2 yelled for his roommate, Resident #1 (who was severely cognitively impaired), to leave his stuff alone and then hit Resident #1 3 times with a closed fist on the back of Resident #1's head and neck. This resulted in Resident #1 being transported to the local emergency department (ED) on 7/13/24, where a computerized tomography (CT) scan of the head determined that Resident #1 had a 4-millimeter (mm) hyperdense focus (increased area of density that could indicate bleeding or a stroke) in the right frontal region of his brain that was questionable for focal hemorrhage, subarachnoid (space between the brain and membrane covering the brain) bleeding, or contusion. [...]

Inspectors wroteBased on record review and staff interviews, the facility failed to report an allegation of resident-to-resident abuse to Adult Protective Services (APS). This deficient practice was for 1 of 3 facility reported incidents reviewed.

Inspectors wroteBased on observation of a breakfast meal test tray, a resident interview (Resident #67), a Resident Council meeting, and staff interviews, the facility failed to provide residents with foods per their preferences for temperature and taste (Residents #3, #7, #15, #24, #47, #58, #64, #67, and #83). This failure had the potential to affect all residents who received food from the dietary department.

Inspectors wroteBased on observations, record review, resident and staff interviews, the facility failed to provide snacks to 7 of 8 residents when requested, (Residents #7, #15, #24, #47, #58, #64 and #83).

Inspectors wroteBased on observations, record review and staff interviews, the facility failed to discard expired and unlabeled food items stored for use, in 1 of 1 reach-in refrigerator, 1 of 1 walk-in refrigerator, and 2 of 4 nourishment refrigerators (halls 100 & 400). The facility also failed to maintain clean ceiling pipes free from tears and stains for 1 of 1 dry goods storage room used to store food served to residents.

Inspectors wroteBased on observations, record review, and staff interviews, the facility's Quality Assessment and Assurance (QAA) Committee failed to maintain implemented procedures and monitor the interventions that the committee put into place following the recertification and complaint investigation survey completed on 06/09/22. This was for one repeat deficiency originally cited in the area of food procurement, store, prepare, serve, sanitary that was subsequently recited on the current recertification and complaint investigation survey of 10/13/23. The continued failure of the facility during two federal surveys of record shows a pattern of the facility's inability to sustain an effective Quality Assessment and Assurance Program.

Inspectors wroteBased on observations, record review, resident interviews, and staff interviews the facility failed to honor a resident's bathing preference of showers for 1 of 2 residents (Resident #96) reviewed for choices.

Inspectors wroteBased on record review, resident and staff interviews, the facility failed to revise care plans to reflect behaviors for 1 of 11 residents whose care plans were reviewed (Resident #32).

Inspectors wroteBased on observations, record review and staff interviews, the facility failed to provide preferences for 1 of 3 sampled residents (#178), reviewed for food preferences.

Inspectors wroteBased on resident and staff interviews and record review, the facility failed to develop a care plan that addressed discharge goals and plans for 5 of 9 residents (Residents #94, #89, # 332, #60, and #27) reviewed for comprehensive care plans.