McCormick Post Acute

Inspectors wroteBased on review of the facility policy, record review, and interviews, the facility failed to ensure Resident (R)1 was free from of accident/hazards, over which the facility had control of on 04/26/25. The facility staff loaded R1, who is a bilateral amputee to his lower extremities, with a Hoyer lift to a boat, allowing him to ride on a highway without being properly secured. On 06/05/25 at 5:39 PM, the survey team provided the Director of Nursing (DON) and the Regional Director of Clinical Services (RDCS) with a copy of the CMS Immediate Jeopardy (IJ) Template, informing the facility IJ existed as of 04/26/25. The IJ was related to 42 CFR 483.25 - Quality of Care at F689- Free of Accident Hazards/Supervision/Devices. On 06/06/25 at 1:14 PM, the facility provided an acceptable IJ Removal Plan. [...]

Inspectors wroteBased on record review, interview, and facility policy review, the facility failed to ensure two residents, Resident (R)83 and R6, were free from resident-to-resident physical abuse for 2 of 3 resident reviewed. Specifically, R103 was able to physically attack R83 on 03/09/25, on three separate occasions, within a forty-five-minute timeframe. Additionally, on 04/14/25, R103 spit on and hit R6. On 05/01/25 at 5:34 PM, the Operation Manager and Director of Nursing were notified that the failure to protect a resident from multiple incidents of physical abuse constituted Immediate Jeopardy (IJ) at F600. On 05/01/25 at 5:34 PM, the survey team provided the Operation Manager and Director of Nursing with a copy of the CMS IJ Template and informed the facility IJ existed as of 03/09/25. The IJ was related to 42 CFR 483.12 - Freedom from Abuse, Neglect, and Exploitation. [...]

Inspectors wroteBased on observation, record review, interview, and facility policy review, the facility failed to ensure the menu was followed regarding menu substitutions displayed on the menu and tray tickets for one of one resident (Resident (R)91) reviewed for menu compliance of 30 sample residents. This had the potential to affect nutritional status and resident preferences for residents who received food from the kitchen.

Inspectors wroteBased on record review, interview, and review of facility policy, the facility failed to ensure an injury of unknown origin, and a fracture was thoroughly investigated for two of five residents (Resident (R)103 and R83) reviewed for abuse out of 30 sample residents.

Inspectors wroteBased on record review, interview, and facility policy review, the facility failed to ensure two of two residents and/or their representatives (Resident (R)56 and R111) reviewed for hospital transfer out of a total sample of 30, were provided with a written transfer notice that contained all required information. This failure has the potential to affect the resident and their Resident Representative (RP) by not having the knowledge of where and why a resident was transferred and/or how to appeal the transfer, if desired.

Inspectors wroteBased on record review, interview, and review of the Resident Assessment Instrument (RAI) manual, the facility failed to ensure comprehensive Minimum Data Set (MDS) assessments were completed and submitted for processing for one of one residents triggered for no MDS in over 120 days, (Resident (R)31), out of a total sample of 30. This failure has the potential to adversely affect the care planning and care provision for any resident that may not have received a comprehensive assessment.

Inspectors wroteBased on record review, interview and review of the Resident Assessment Instrument (RAI) manual, the facility failed to complete a significant change assessment for a resident receiving hospice services for one of three residents, (Resident (R)112), reviewed for hospice.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure that one of two residents, (Resident (R)28), reviewed for skin conditions out of a sample of 30 residents received documented skin assessments identifying the status of the skin. In addition, the facility failed to ensure a resident was appropriately screened and had documentation to support the use of a wander guard for one of two residents, (Residents (R)106), reviewed for wander guards in the sample of 30 residents.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to ensure ongoing communication and collaboration with the dialysis facility for one resident (Residents (R)108) reviewed for dialysis out of a sample of 30 residents. This had the potential to affect all residents receiving dialysis treatment.

Inspectors wroteBased on observation, interview, record review, and Food Drug Administration guidance, the facility failed to ensure a resident was appropriately evaluated for use of bedrail and that alternative measures were attempted prior to installation of side rails for one of one resident (Resident (R)27) reviewed for side rails out of a total sample of 22. The lack of alternate side rail measures had the potential to lead to safety concerns related to bed rail use.

Inspectors wroteBased on observation, record review, interview, and facility policy review, the facility failed to ensure resident preferences were followed for one of one resident (Resident (R)91) reviewed for food preferences of 30 sample residents. This had the potential to affect nutritional status and resident preferences for residents who received food from the kitchen.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to ensure that Residents (R)34, R47, and R84 or the Resident Representatives (RRs) reviewed for signing the Arbitration Agreement had the agreement clearly explained to ensure the signatories were fully aware of the consequences of signing the agreement.

Inspectors wroteBased on review of facility policy, record reviews and interviews, the facility failed to ensure a resident had a safe and orderly discharge from the facility, for 1 of 1 resident. Specifically, Resident (R)1 was discharged from the facility on 04/14/23 to a motel located approximately 50 minutes from facility. Upon arrival to the motel, R1 suffered an emergent event and had to be transported to an emergency room. On 04/09/24 at 3:00 PM, the Director of Nursing and Regional Director of Clinical Services was notified that the failure to ensure a resident had a safe and orderly discharge from the facility constituted Immediate Jeopardy (IJ) at F624. On 04/09/24 at 3:04 PM, the survey team provided the Director of Nursing with a copy of the CMS Immediate Jeopardy (IJ) Template and informed the facility IJ existed as of 04/14/23. [...]

Inspectors wroteBased on observation, record review, interview, and facility policy review, the facility failed to ensure a Preadmission Screening and Resident Review (PASARR) level I was completed correctly for two resident (Resident (R) 64 and R65) of four reviewed for PASARR I in a total sample of 38 residents.

Inspectors wroteBased on observation, interview, record review and policy review, the facility failed to ensure oxygen was administered per physician orders and ensure there was an order in place for oxygen administration for two (Residents (R)23 and R103) reviewed for oxygen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff properly stored nebulizer masks when not in use for one of one sampled resident (Resident (R) 103).

Inspectors wroteBased on observation, interview, and policy review, the facility failed to ensure floors, ceiling, vents, equipment, and walls throughout the kitchen were kept clean and/or in good repair and foods were stored and/or labeled. This deficient practice had the potential to affect 85 of 87 residents who received meals prepared in the facility's only kitchen.

Inspectors wroteBased on observation, interview, and review of facility policies, the facility failed to ensure a homelike environment in 11 out of 62 resident rooms in the facility. Specifically, 11 resident bathroom had significant rust on handrails and were in need of repair.

Inspectors wroteBased on interview and record review, the facility failed to ensure a documented date and method of notification for two residents' (Resident (R) 18 and R89) or Resident Representative (RR)'s choice of acceptance or denial of advanced benefits was documented on the Advanced Beneficiary Notice (ABN) form for two of two ABNs reviewed.

Inspectors wroteBased on record review, interview, and review of facility policy, the facility failed to develop a person-centered comprehensive care plan to meet resident preferences and goals for one resident of two residents (Resident (R) 27) reviewed for hospice.

Inspectors wroteBased on observation, interview, medical record review, and review of facility policies, the facility failed to ensure appropriate care of the respiratory suction equipment for one resident out of one resident (Resident (R) 57) with a tracheostomy in the facility.