Memorial City Nursing and Rehabilitation Center

Inspectors wroteBased on interview, and record review, the facility failed to ensure resident had the right to be free from abuse, neglect, misappropriation of resident property, and exploitation for 1 of 13 residents (Resident #21) reviewed for abuse. The facility failed to ensure Resident #21 remained free from abuse when LVN A removed the resident's property (cell phone) as a way to restrict the resident's communication (preventing calls to 911). These failures could place residents at risk of an unsafe environment and unprotected from mistreatment.

Inspectors wroteBased on interviews, and record reviews, the facility failed to ensure that pain management was provided to Resident #21's who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences. The facility failed to monitor and address Resident #21's pain on 03/04/2026 from 3:00 a.m. to 11:00 a.m., when Resident #21 pressed her call light, cried out in pain, called 911 twice, and pulled the fire alarm requesting to go to the hospital. This failure had the potential to place residents at risk for delayed treatment, pain, and actual harm.

Inspectors wroteBased on record reviews and interviews, the facility failed to ensure each resident is offered the COVID-19 (infectious respiratory illness caused by the corona virus) vaccine unless the immunization is medically contraindicated, or the resident has already been immunized for all residents. The facility failed to offer COVID vaccine to its residents upon admission to the facility. This failure could place residents at risk of COVID.

Inspectors wroteBased on observation, interview and record reviews, the facility failed to ensure the resident had the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents for 1 of 8 residents (Resident #38) reviewed for call light placement. The facility failed to ensure Resident #38's call light was within reach on 04/24/2026, while he was lying in bed. These failures could place residents at risk of not receiving immediate assistance when needed.

Inspectors wroteBased on record review and interview, the facility failed to ensure that a written notice of transfer or discharge, was provided to the resident and/or their representative contained all federally mandated elements for 1 of 4 residents (Resident #40) reviewed for discharge notices. The facility failed to ensure that Resident #40's written notice of transfer or discharge, including a safe discharge location. The facility failed to ensure that Resident #40's written notice of transfer or discharge, contained the Ombudsman's name and email address. These failures could place the residents at significant risk by bypassing critical safeguards meant to ensure their safety and continuity of care.

Inspectors wroteBased on interview and record review, the facility failed to transmit encoded, accurate, and complete MDS data to the Center for Medicaid/Medicare System (CMS) System for 1 of 6 closed records (CR #154) reviewed for Minimum Data Set (MDS) transmission. - The facility failed to complete and retransmit CR #154's MDS discharge assessment within 14-days of CR #154's discharge when the anticipated return had not resulted in a readmission. This failure could place residents at risk of not having assessments completed and submitted in a timely manner as required.

Inspectors wroteBased on observations, interviews and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 2 of 10 residents (Resident #30, Resident #41) reviewed for medication storage and labeling. The facility failed to ensure nurses dated Residents #30 and 41's opened insulin glargine (a medication prescribed to help the body manage blood sugar levels) pens and discarded them within 28 days of opening, on 04/24/2026. This failure could place residents at risk of receiving medications that were less effective or expired and the risk of contamination or chemical degradation (change of a substance into something else, often making it weaker, useless, or harmful).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents who were unable to carry out activities of daily living received necessary services to maintain grooming and personal hygiene for 3 out of 8 residents (Resident #22, Resident #17, and Resident #24) reviewed for ADLs.1. The facility failed to provide scheduled showers and/or bed baths on M/W/F to Resident #22 on 9/17/25, 9/19/25, 9/22/25, 9/26/25, 10/1/25, 10/3/25, 10/6/25, 10/8/25, 10/10/25, 10/13/25, and 10/15/25.2. The facility failed to provide scheduled showers and/or bed baths on M/W/F to Resident #17 on 9/17/25, 9/19/25, 9/22/25, 9/24/25, 9/26/25, 9/29/25, 10/1/25, 10/3/25, 10/6/25, 10/8/25, and 10/10/25.3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to adequately equip to allow residents to call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area from each resident's bedside for 1 (Residents #35) of 6 residents reviewed for call lights.-Residents #35 did not have her call light within reach while she was in bed. This failure could lead to residents not being able to request and receive prompt medical care and result in injury and harm. Record review of Resident #35's face sheet dated 10/16/2025, she was a [AGE] year-old female originally admitted on [DATE] with medical diagnoses including vascular dementia, bipolar disorder, generalized anxiety disorder, Alzheimer's Disease, hypertension, cognitive communication deficit and other abnormalities of gait and mobility. [...]

Inspectors wroteDuring observations, interviews, and record review, the facility failed to maintain an effective pest control program so that the facility is free of pests for the 300 and 400 halls, in that: The facility continues had an infestation of roaches in Residents' rooms as observed in the following: 317,321,323, 327 and 405. This failure could expose Residents to infection and decreased quality of life. During observations, interviews, and record review, the facility failed to maintain an effective pest control program so that the facility is free of pests for the 300 and 400 halls, in that: The facility continues had an infestation of roaches in Residents' rooms as observed in the following: 317,321,323, 327 and 405. This failure could expose Residents to infection and decreased quality of life. [...]

Inspectors wroteBased on observations, interviews, and record review the facility failed to provide a safe, clean, comfortable, and homelike environment including but not limited to receiving treatment and supports for daily living safely for 5 (Residents #21 #22, #44, #51 and #108) of 16 residents reviewed for cleanliness and sanitization. 1. The facility failed to address damaged and unclean walls in Residents #22, #44, and 51's room. 2. Resident #21's headboard was loose and moving back and forth. 3. Resident #108's wash basin on the nightstand that was not labeled and there was another wash pan in the bathroom that was not labeled or bagged. These deficient practices could place residents at risk of living in an unclean and unsanitary environment which could lead to a decreased quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that a resident needing respiratory care, including tracheostomy care, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals and preferences for 6 of 8 (Residents #14, #21, #11, #17, #43 and #86) reviewed for oxygen. Resident #14's continuous oxygen was observed set at 8L/min on 02/11/2025 when he had a physician order for continuous oxygen at 6L/min. Resident #21's nebulizer machine was on the floor on the left side of his bed. The resident had respiratory tubing that was attached to a mask hanging on wheelchair at the bedside. Resident #11's nebulizer tubing and mask was not dated and placed inside of plastic bag when not in use. [...]

Inspectors wroteThe facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infections and follow standard and transmission-based precautions to be followed to prevent spread of infections for 1 of 24 (Resident #14) residents reviewed for infection control. During tracheostomy care for Resident #14, RN A and LVN B failed to properly dispose of used materials in a biohazard bag after completing care. This failure could put residents at risk of exposure to infection and cross contamination.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain an effective pest control program so that the facility is free of pests and rodents for 2 of 2 (Residents #23, #50) resident rooms reviewed for environment. Resident #23 had a live roach in their bed during medication pass Resident #50 had a spider on the wall in their room near the bed . This failure could lead to spread of disease and a decline in resident health from preventable pest control.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe, clean, comfortable, and homelike environment in one (right side) of two shower rooms on Hall 400. -The facility failed to clean the shower room on the right side of Hall 400 that was observed with soiled towels, gloves, empty containers of personal care items, hair on the floor, and the floor had brown and black stain marks. This failure placed residents at risk for receiving showers in an unclean and uncomfortable environment.

Inspectors wroteBased on record review and interview, the facility failed to maintain medical records on each resident that are accurately documented for 1 of 5 (Resident #50) residents reviewed for care plans. The facility failed to have accurate Physician Orders for Resident #50 when anticoagulant medication monitoring was ordered without an order for an anticoagulant. This deficiency could put residents at risk of improper medication administration and inaccurate documentation and tracking of residents' condition and treatment.

Inspectors wroteBased on observation, interviews, and record review the facility failed to ensure based on the comprehensive assessment of a resident, residents received care, consistent with professional standards of practice, to prevent pressure ulcers and did not develop pressure ulcers unless the individual's clinical condition demonstrated that they were unavoidable; and a resident with pressure ulcers received necessary treatment and services consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for one (CR#1) of five residents reviewed for pressure ulcers . The facility failed to ensure CR #1 did not acquire an unstageable pressure ulcer to her bilateral buttock. This failure could place residents at risk for developing pressure wounds, Cellulitis (skin infection), Sepsis (infection of the blood) and severe pain.

Inspectors wroteBased on observations, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and timeframes to meet a resident medical, nursing, mental, and psychosocial needs for 1 (Resident #1) of 3 residents reviewed for care plans in that: The facility failed to ensure Resident #1 bed was in the lowest position per care plan while he was in the bed. The facility failed to update falls and interventions for Resident #1's care plan after his last 3 falls. This failure placed facility residents who were fall risk at risk of serious harm and injury. An Immediate Jeopardy (IJ) was identified on 9/18/2024. The IJ template was provided to the Administrator In-Training and DON on 9/18/2024 at 12:46 p.m. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 4 residents (Resident #1) reviewed for free of accidents, hazards, supervision, and devices., in that: The facility failed to ensure precautionary interventions in place Resident #1, while he was prescribed an anticoagulant, who was a known fall risk that resulted in falls with injuries to the head and hospitalization. An IJ was identified on 9/17/2024. The IJ template was provided to the AIT and DON on 9/17/2024 at 5:06 p.m. While the IJ was removed on 9/20/2021 at 12:31 p.m., with the ADMIN and DON. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents had a safe, clean, comfortable, and homelike environment for 1 of 10 resident (Resident #2) reviewed for homelike environment. The facility failed to ensure Resident #2's toilet base was free from stains and dirt and toilet was in good repair. These failures could place residents at risk of a diminished quality of life due to exposure to an environment that is unpleasant, unsanitary, uncomfortable, and unsafe.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an effective pest control program for 4 (Resident #4, Resident #2, Resident #1 and Resident #3) of 4 residents and 1 of 4 nurses' stations reviewed for pests, in that: 1. Numerous gnats were observed in a resident room on Hall 300 (Resident #4, Resident #2, Resident #1 and Resident #3 rooms). 2. There was live medium size roach at hall 300's nurses' station. This deficient practice could place residents at risk of residing in an environment with pests and decrease quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to treat each resident with respect and dignity and provide care in a manner that promoted maintenance or enhancement of his or her quality of life for 4 of 4 residents (Resident #1, Resident #2, Resident #3, Resident #4) reviewed for resident rights. The facility failed to ensure staff assisted Resident #1, Resident #2, Resident#3 and Resident #4, by failing to answer call lights in a timely manner to provide assistance. This failure could place residents at risk for decreased quality of life, decreased self-esteem and increase anxiety.

Inspectors wroteBased on observation, interview, and record review, the facility failed to treat each resident with respect and dignity and provide care in a manner that promoted maintenance or enhancement of his or her quality of life for 4 of 4 residents (Resident #1, Resident #2, Resident #3, Resident #4) reviewed for resident rights. The facility failed to ensure staff assisted Resident #1, Resident #2, Resident#3 and Resident #4, by failing to answer call lights in a timely manner to provide assistance. This failure could place residents at risk for decreased quality of life, decreased self-esteem and increase anxiety.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to maintain an effective pest control program so that the facility was free of pests for two (hall 100 & 300) of three halls, in that: The facility continues to have an infestation of roaches in residents' rooms, nursing stations, on medication carts, hallways and reception area. This failure placed residents, visitors, facility, and staff at risk of pest infestation, and a negative impact on the physical environment and cleanliness of the facility.

Inspectors wroteBased on interviews and record review, the facility failed to ensure residents requiring respiratory care, consistent with professional standards of practice for 1 (CR#1) of 5 residents reviewed for quality of care. The facility failed to provide immediate care to CR#1 when she experienced respiratory distress on 05/08/24. After the resident was observed gurgling with emesis by LVN A, the NP was notified; monitoring nor interventions were initiated. When observed by the NP, CR #1 was unresponsive and oxygen saturation dropped to 60%. 911 was called and arrived at 12pm. During the course of hospitalization, CR #1 was declared brain dead and expired on 05/13/24 after atifical support was removed. This failure placed residents who developed a change in respiratory status at risk of physical harm, emotional distress, mental anguish, and hospitalization or death from possible neglect.

Inspectors wroteBased on observation, interview, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infection for 1 of 4 residents (Resident #1) reviewed for infection. -The facility failed to ensure CNA A performed hand hygiene during incontinent care on Resident #1. This failure could lead to the spread of infection to residents, resident illness, and/or resident distress.

Inspectors wroteBased on observation, interview, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for food procurement in that 9 Frozen rolls of 10 lb. ground beef in a pan being thawed in the sink. This failure could affect residents who ate food from the kitchen and place them at risk of food borne illness and disease. Findings Included: Observation of the facility kitchen on 12/12/23 at 8:30 AM revealed 9- 10 lb. frozen ground beef in a pan being thawed in the sink faucet water running with a temperature of 118 degrees Fahrenheit. Ground beef had an internal temperature of 73.8 degrees Fahrenheit ; 54 degrees Fahrenheit indicating that the temperature is in the Danger Zone (41 degrees Fahrenheit to 135 degrees Fahrenheit). [...]

Inspectors wroteBased on observation, interview and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for of 1 resident (Residents #93 ) reviewed for infection control practices. 1. CNA A did not utilize appropriate hand hygiene during incontinent and Foley catheter care for Resident #93 2. RN A did not utilize appropriate hand hygiene and cross contamination during medication administration for Resident #93 These failures could place residents at risk of infection or a decline in health.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections for 1 of 2 residents (Residents #93) reviewed for indwelling catheters. -The facility failed to ensure Resident #93's Foley catheter (F/C) (tubing inserted into the bladder to drain urine) was secured to her leg to prevent stress or pulling on the catheter site. These failures could place residents at risk for discomfort, urethral trauma, and urinary tract infections.

Inspectors wroteBased on interview and record review, the facility failed to provide pharmaceutical services including procedures that assure the accurate acquiring and administering of all medications to meet the needs of each resident for one (Residents #93) of six residents reviewed for pharmacy services. 1. RN A failed to follow the manufacturer's instructions not to crushed Gas Ban Anti Gas ( Simethicone 80 mg used to farting ) administered to Resident #93. These failures placed residents at risk of not receiving full dosage of medication.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with the professional standards for food service safety in 1 of 1 kitchen reviewed for kitchen sanitation. -The facility failed to ensure foods were properly stored, labeled, and dated. This failure could place residents who ate food served by the kitchen at risk of food-borne illness.

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain an effective pest control program so that the facility is free of pests and rodents for three (Resident #1, Resident #2 and Resident #3's room) of five rooms as evidence by: Roaches were in 3 resident's rooms (Resident #1, Resident #2 and Resident #3's room) . This failure could place all residents in the facility at risk of illness and decreased quality of life.