Matthews Memorial Health Care Center

Inspectors wroteBased on record review and interview, the facility failed to develop and implement a baseline care plan within 48 hours of admission for 1 (Resident #3) of 3 sampled residents.

Inspectors wroteBased on interview and record review, the facility failed to develop a comprehensive, person-centered care plan for services to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 (Resident #3) of 3 sampled residents. The facility failed to develop a comprehensive care plan that addressed Resident #3's medical, physical, mental, and psychosocial needs.

Inspectors wroteBased on observation, record review, and interview, the facility failed to provide care and services that met professional standards of quality by failing to obtain and document blood pressure measurements in accordance with physician orders and prior to administering medications with prescribed blood pressure parameters for 1 (Resident #3) of 3 sampled residents.

Inspectors wroteBased on interview and record review, the facility failed to accurately assess acute pain consistent with professional standards of practice for 1 (Resident #1) of 3 sampled residents.

Inspectors wroteBased on record review and an interview, the facility failed to ensure a resident's medical record was accurately documented in accordance with accepted professional standards and practices for 1 (Resident #1) of 3 sampled residents. The facility failed to ensure Resident #1's pain level and meal intake was accurately documented in the electronic medical record.

Inspectors wroteBased on record review and interview, the facility failed to provide care and services that met professional standards of quality by failing to ensure physician orders for blood glucose monitoring were implemented for 2 (Resident #1 and Resident #2) of 3 residents sampled.

Inspectors wroteBased on record review and interview the facility failed to provide pharmaceutical services to ensure procedures that assure accurate acquiring, receiving, dispensing and administration of medications to meet the needs of each resident. The facility failed to provide medications and/or biologicals to meet the needs of residents for 2 (Resident #1 & Resident #3) of 3 residents sampled. FindingsResident #1Review of Resident #1's medical record revealed an admit date of 02/12/2026 with the following diagnoses in part. Chronic Kidney Disease, Type 2 Diabetes Mellitus with Hyperglycemia, Dementia, Essential Hypertension, Cognitive Communication Deficit, and Generalized Muscle Weakness. Review of Resident #1's admission MDS with an ARD of 02/13/2026 revealed a BIMS score of 6, which indicated severe cognitive impairment. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents received services and resources in the facility with reasonable accommodation of resident needs by failing to:Ensure 1 (#2) of 5 residents reviewed had a call light in place that accommodated his/her needs; and Ensure a call light was within reach in order to call for assistance for 4 (R5, R6, R7, and R8) of 5 residents reviewed for accommodation of needs. Resident #2 Review of Resident #2's medical record revealed an admission date of 09/11/2020 with diagnoses that included, in part. Hemiplegia and Hemiparesis following Unspecified Cerebrovascular Disease affecting the Left Non-Dominant Side, Type 2 Diabetes Mellitus, Aphasia, Dysphagia, Functional Quadriplegia. Review of Resident #2's annual MDS with ARD 1/15/2026 revealed a BIMS score of 3, indicating severe cognition impairment. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that 2 (Resident #1 and Resident #3) of 3 (Resident #1, Resident #2, and Resident #3) sampled residents received services and treatments necessary to promote wound healing. Review of facility policy titled Prevention and Treatment of Skin Issues, revised 09/2025, revealed in part. Policy: It is the policy to properly identify and assess residents whose clinical conditions increase risk for impaired skin integrity and pressure ulcers; to implement preventative measures; and to provide appropriate treatment modalities for wounds according to industry standards of care. Resident #1Review of Resident #1's clinical record revealed an admission date of 03/07/2024, with diagnoses that included, in part,. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe and homelike environment by not ensuring systems were in place to protect residents' personal belongings, resulting in missing items for 2 ( Resident #34 and Resident #55) of 34 sampled residents.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure individuals with a mental disorder were referred for a PASRR Level II review for 2 (Resident #26 and Resident #56) of 2 residents sampled for PASRR.

Inspectors wroteBased on observation, interview, and record review the facility failed to implement a comprehensive person-centered care plan for 2 (Resident #16 and Resident #57) of 34 sampled residents. The facility failed to ensure Resident #16 wore a fire resistant apron while smoking and failed to ensure EBP were implemented for Resident #57.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents who are unable to carry out ADLS (Activities of Daily Living) received the necessary services to maintain good personal hygiene for 2 ( #59, and #76) of 4 (#1, #59, and #76, and #86) residents reviewed for ADL care. The facility failed to ensure:11. Resident #59 was provided nail care and was shaved; and 2. Resident #76 was provided proper hair care.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure 1 (Resident #10) of 3 ( Resident #10, Resident #57, and Resident #86) sampled residents received the necessary treatment and services to prevent and promote the healing of pressure ulcers by failing to perform hand hygiene during treatment of a pressure ulcer.

Inspectors wroteBased on interview and record review, the facility failed to implement, monitor, and modify interventions, consistent with the resident's assessed needs and current professional standards of practice, to maintain acceptable parameters of nutritional status for 1 (Resident #86) of 1 resident sampled for nutrition.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. The facility failed to ensure:1. EBP were utilized for 1 (Resident #57) of 3 residents reviewed for pressure ulcers;2. Staff performed proper hand hygiene while feeding residents; 3. Staff followed proper infection prevention and control practices during transport of soiled linens; and4. Staff followed proper infection prevention and control practices while laundering resident clothing.

Inspectors wroteBased on record review and interview, the facility failed to ensure services were provided to meet professional standards of practice for 1 (#3 of 3 (Resident #1, Resident #2, and Resident #3) sampled residents and 1 (Resident #R1) of 1 random resident. The facility failed to:1. Ensure Resident #3's physician was notified of and immediately responded to the request of an antibiotic for a tooth abscess; and 2. Ensure Resident #R1's received wound care as ordered by the physician.

Inspectors wroteBased on record review and interview the facility failed to immediately inform the resident, consult the resident's physician; and notify, consistent with his or her authority, the resident representative(s) when there is an accident involving the resident which results in injury and has the potential for requiring physician intervention for 1 (Resident #2) of 3 (Resident #1, Resident #2, and Resident #3) resident records reviewed for falls.

Inspectors wroteBased on interview and record review the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice for 2 (Resident #27 and Resident #64) of 29 sampled residents reviewed for quality of care.

Inspectors wroteBased on record review and interview, the facility failed to ensure pain management was provided to residents who require such services, consistent with professional standards of practice and the comprehensive person-centered care plan for 2 (#4, #64) of 2 residents reviewed for pain. The facility failed to ensure Resident #4 and #64, who reported pain, received medication or interventions to alleviate pain.

Inspectors wroteBased on interview and record review, the Facility failed to provide pharmaceutical services that assure the accurate reconciliation of controlled medications to meet the needs of each Resident by failing to ensure at each shift change a physical inventory of controlled medications were conducted by two licensed clinicians.

Inspectors wroteBased on observations, interviews and record review the facility failed to ensure snacks are served at times in accordance with resident's needs, preferences and requests. The facility failed to provide snacks for residents outside of scheduled meal service times. The facility failed to ensure that Residents meals were distributed in a timely manner. Findings. Interviews on 09/08/2024 at 2:00 p.m. with residents during the Resident Council meeting revealed snacks were not being provided and were not available at all times. Residents in the council meeting stated they would ask for snacks and the nurse would tell them dietary did not leave any out for them. Residents stated snacks were labeled with residents names on them, and if your name was not on a snack you did not get a snack. Observation on 09/08/2024 at 9:44 a.m. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure Residents who are unable to carry out ADLS (Activities of Daily Living) received the necessary services to maintain good grooming and personal hygiene for 2 (#2 and #82) of 2 (#2 and #82) Residents reviewed for ADL's. The facility failed to ensure Resident's (#2 and #82) were shaved.

Inspectors wroteBased on record review, observation, and interview the facility failed to ensure a resident with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing and to prevent infection for 1 (#188) of 2 (#2, #188) residents reviewed for pressure ulcers. The facility failed to ensure Resident #188's wounds were accurately assessed and documented weekly.

Inspectors wroteBased on observation, interview and record review the facility failed to provide respiratory care consistent with professional standards for 1 (Resident #54) of 1 sampled residents reviewed for respiratory care. The facility failed to ensure respiratory equipment was properly labeled and stored.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to ensure each resident received adequate supervision and assistive devices to prevent accidents for 1 Resident (#3) of 3 sampled Residents (#1, #2, and #3). The facility failed to ensure that Resident #3 was safely secured in a shower chair prior to showering. This deficient practice resulted in an actual harm for Resident #3 on 04/19/2024 at approximately 7:30 p.m., when Resident #3 was placed in a shower chair that was not equipped with a safety belt. Resident #3 fell from the shower chair to the floor, after being showered by S5 CNA. Resident #3 was transferred to the emergency room and diagnosed with a Displaced Left Intertrochanteric Femur Fracture. Resident #3 required surgical intervention of an Intramedullary Nail placement, Left Intertrochanteric Femur Fracture, on 04/21/2024.

Inspectors wroteBased on interview and record review the facility failed to immediately consult with the physician, and notify the resident's representative when a resident experienced a fall for 1 Resident (#1) of 3 (Resident#1, Resident #2, Resident #3) sampled residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure prompt efforts were made by the facility to resolve a grievance filed by a resident's Responsible Party, for 1 (Resident #1) of 3 (Resident #1, Resident #2, and Resident #3) sampled residents.

Inspectors wroteBased on record review and interview the facility failed to ensure a resident received services in accordance with professional standards. The facility failed to ensure physician's orders were followed for wound care for 1 (#2) of 1 sampled resident reviewed for wound care.

Inspectors wroteBased on observation and interview the facility failed to maintain a clean, comfortable, and homelike environment by failing to ensure resident's shower rooms were clean, sanitary, and in good repair for 2 (Hall X and Hall Y) of 2 (Hall X and Hall Y) shower rooms observed. The facility failed to ensure medication carts were clean and sanitary for 2 of 3 medication carts observed for medication storage. The facility failed to ensure residents' assistive devices were maintained in good working condition for 1(Resident #19) of a sample size of 31 Residents. The facility failed to maintain the air conditioner units in sanitary condition in 2 (Room A and Room B) of 2 (Room A and Room B) rooms observed for air conditioner filter status. The facility failed to ensure that the designated smoking area was maintained in a clean, safe, and comfortable environment for all smokers in the facility. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that residents who were unable to carry out ADLs (Activities of Daily Living) received the necessary services to maintain good grooming and personal hygiene. The facility failed to provide shaving, and nail care to dependent residents for 4 (Resident #2, Resident #19, Resident #56 & Resident #78) of 31 sampled residents.

Inspectors wroteBased on record review and interview, the facility failed to have sufficient nursing staff to provide nursing and related services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident by: 1. Failing to answer or respond to call light in a timely manner for 5 (#6, #9, #17, #18, #34) residents out of a total sample of 31, 2. Failing to provide incontinent care for residents who require assistance in a timely manner for 2 (#17 and #42) out of a total sample of 31, 3. Failing to honor resident's preferences for bedtime for 1 (#18) out of 31, 4. Failing to bathe residents who require assistance for 2 (#31 and #51) out of a total sample of 31, and 5. Failing to round or check in on residents who require assistance every two hours for 1 (#6) out of a total sample of 31.

Inspectors wroteBased on observation and interview the facility failed to ensure that food was stored in accordance with professional standards for food service. This deficient practice had the potential to affect the 82 residents that received meals prepared by the kitchen.

Inspectors wroteBased on record review and interview, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 (#3) of 2 (#3, #238) residents reviewed for hospice. The facility failed to collaborate with Resident #3's hospice provider in order to honor the resident's choices regarding end of life care.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure 1 (Resident #57) of 1 sampled residents reviewed for pressure ulcers, received the necessary treatment and services to prevent and promote wound healing. The facility failed to ensure staff applied Resident #57's heel protectors as ordered.