McMahon-Tomlinson Nursing Center

Inspectors wroteBased on record review and interview, the facility failed to ensure a comprehensive care plan was developed to include skin integrity for 1 (#7) of 12 sampled residents whose care plans were reviewed. The administrator identified 122 residents resided in the facility.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure staff implemented proper infection control practices while performing incontinent care for 2 (#10 and #11) of 2 sampled residents observed for incontinent care. The director of nursing identified 68 residents required assistance with incontinent care.

Inspectors wroteBased on record review and interview, the facility failed to ensure an allegation of abuse was reported to the state agency within the 2-hour required timeframe for 1 (#1) of 3 sampled residents reviewed for abuse. The DON reported the facility census was 133. Listed below are abbreviations that will be used throughout this document. ADON - Assistant Director of Nursing APS - Adult Protective ServiceBIMs score - Brief Interview for Mental StatusDON - Director of Nursing A Abuse and Neglect policy, dated 09/12/25, read in part, The facility shall immediately report allegations, suspicions, or incidents of abuse, neglect, exploitation, misappropriation of resident property, or injuries of unknown source involving residents. The admission assessment, dated 12 /05/25, showed Resident #1 was admitted to the facility on [DATE] with diagnosis of congestive heart failure. [...]

Inspectors wroteBased on record review and interview, the facility failed to ensure an allegation of abuse was investigated to make certain residents were free from abuse for 1 (#1) of 3 sampled residents reviewed for abuse. The DON reported the facility census was 133. Listed below are abbreviations that will be used throughout this document. ADON - Assistant Director of NursingAPS - Adult Protective ServiceBIMS score - Brief Interview for Mental StatusDON - Director of NursingA Abuse and Neglect policy, dated 09/12/25, read in part, The facility shall immediately report allegations, suspicions, or incidents of abuse, neglect, exploitation, misappropriation of resident property, or injuries of unknown source involving residents. The admission assessment, dated 12 /05/25, showed Resident #1 was admitted to the facility on [DATE] with diagnosis of congestive heart failure. [...]

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure wound care was provided per physician orders for 1 (#31) of 2 sampled residents reviewed for wound care. The DON identified 123 residents resided in the facility.

Inspectors wroteBased on observation, record review, and interview, the facility failed to follow physician's orders and care plans to prevent the worsening of wounds for 1 (#31) of 2 sampled residents reviewed for wound care. The DON identified 123 residents resided in the facility.

Inspectors wroteBased on record review and interview, the facility failed to ensure the minimum data set was coded accurately for Legionella for 1 (#1) of 1 sampled discharged resident from the hospital for skilled services. The DON/IP reported one case of Legionella.

Inspectors wroteBased on record review and interview, the facility failed to update a care plan for 1 (#1) of 1 sampled resident with a new diagnosis of Legionella. The DON/IP reported one case of Legionella.

Inspectors wroteBased on record review and interview, the facility failed infection prevention and control practices to ensure identification of high risk areas to include flushing of unused outlets to prevent the spread of a waterborne illness. The DON/IP reported 118 residents resided in the facility.

Inspectors wroteBased on record review and interview, the facility failed to ensure assessments were accurate for two (#83 and #87) of 22 sampled residents reviewed for assessments. The Administrator identified 97 residents resided in the facility.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure interventions were added to the care plan after a fall for two residents (#38 and #41) of 20 sampled residents reviewed for care plan revisions. The DON identified 97 Residents resided in the facility.

Inspectors wroteBased on record review and interview the facility failed to ensure neurological checks were completed after unwitnessed falls for one (#41) of three sampled residents reviewed for falls. The Administrator identified 97 residents resided in the facility. The Resident Matrix documented 21 residents had falls.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure; a. oxygen tubing was labeled and dated, per the facility policy and professional standards of care, for three (#14,64, and #143) and, b. respiratory medications were administered per the standard of practice for one (#64) of three residents sampled for respiratory care. The DON identified 11 residents received oxygen services.

Inspectors wroteBased on record review and interview, the facility failed to ensure a. the resident assessment at the dialysis center was communicated between the dialysis center and nursing staff was in place, and b. pre- and post- dialysis assessments were completed by the facility for one #63) of one resident reviewed for dialysis. The DON stated four residents received dialysis.

Inspectors wroteBased on record review and interview, the facility failed to ensure Registered Nurse coverage was provided 8 hours per day for 7 days a week for nine (10/01/23,10/07/23,10/15/23,10/22/23,11/11/23,11/19/23,12/03/23,12/09/23, and 12/17/23 of 92 days sampled for RN coverage. The DON identified 97 Residents resided in the facility.

Inspectors wroteBased on observation, record review, and interview the facility failed to ensure three extended release medications were not crushed for two (#6 and #23) of eight sampled residents reviewed during medication pass. A total of 39 opportunites were observed with three errors. The medication error rate was 6.94%. The Administrator identified 97 residents resided in the facility.

Inspectors wroteBased on observation, record review and interview the facility failed to ensure staff maintained infection control measures, and a. changed gloves during provision of perineal care and personal hygiene for one (#55) of one sampled resident reviewed for perineal care, b. sanitized the blood pressure cuff and pulse oximeter during medication observation for three (#6, #64, and #23), and c. sanitized their hands between residents during medication observation for four (#17, #31, #144, #80) of eight sampled residents reviewed during medication pass observation. The Administrator identified 97 residents resided in the facility.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure interventions were implemented for one (#14) of three residents sampled for falls. The DON identified 97 Residents resided in the facility.

Inspectors wroteBased on record review and interview, the facility failed to identify the time frames for the steps regarding the medication regimen review, and a medication regimen review was responded to timely for one (#45) of five sampled residents reviewed for unnecessary medications. The Administrator identified 97 residents resided in the facility.

Inspectors wroteBased on record review and interview, the facility failed to ensure side effect monitoring was in place for a resident who was prescribed anticoagulant therapy for one (#3) of five residents sampled for unnecessary medication. The DON identified 29 residents were prescribed anticoagulants.

Inspectors wroteBased on record review, observation, and interview, the facility failed to assess residents for the use of bed rails, educate residents and/or representatives on the risks and benefits of bed rails, and obtain an informed consent prior to the installation of bed rails for two (#15 and #16) of two sampled residents reviewed for bed rails. The Director of Nursing reported 62 residents with bed rails in place.

Inspectors wroteBased on record review, observation, and interview, the facility failed to conduct regular inspections of beds, mattresses, and bed rails, as part of a regular maintenance program, for two (#15 and #16) of two residents reviewed for bed and bed rail inspections. The Resident Census and Conditions of Residents form documented 87 residents resided in the facility.

Inspectors wroteBased on record review, observation, and interview, the facility failed to have a medical justification for an indwelling urinary catheter (Foley catheter), and assess for removal of the catheter, for one (#10) of four residents reviewed for indwelling urinary catheters. The Resident Census and Conditions of Residents form documented seven residents with indwelling or external catheters.