Memorial Health Care Center

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide information to resident's and their representatives on their rights related to filing grievances or concerns for 10 of 42 confidential residents. The facility failed to ensure 10 confidential residents were provided, the Grievance Procedure, information in regards to who the facility grievance officer was, their contact information, how to file an anonymous grievance. This failure could place the residents at risk of unresolved grievances and decreased quality of life.

Inspectors wroteBased on interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that include measurable objectives and timeframes to meet a resident's medical, nursing, mental, and psychosocial needs that were identified in the comprehensive assessment for 4 of 16 residents (Resident #29, Resident #36, Resident #39, and Resident #42) reviewed for care plans. The facility failed to develop a care plan for Resident #29's, Resident #36's, Resident #39's and Resident #42's advanced directives. These failures could place residents at risk of not receiving the care required to meet their individualized needs.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure the personal food policy was followed to maintain safe and sanitary storage of residents' food items for 4 of 16 residents rooms reviewed for food safety (room [ROOM NUMBER]A, #16B, #19B, and #21B) in that: The refrigerators located in room [ROOM NUMBER]A, #16B, #19B, and #21B were not being monitored for internal temperature and expiration/used by dates. These failures could place residents at risk for food borne illnesses.

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 2 of 3 residents (Residents #39 and #29) reviewed for infection control.1. CNA A failed to utilize proper hand hygiene between glove changes and failed to change gloves when going from dirty to clean when providing incontinence care and catheter care for Resident #39. 2. CNA A and RN B failed to follow enhanced barrier precautions (EBP) and wear a gown when providing incontinence care and catheter care for Resident #39. 3. CNA C failed to change her gloves when going from dirty to clean when providing incontinence care for Resident #29. [...]

Inspectors wroteBased on record reviews and interviews the facility failed to develop, implement, and maintain an effective training program for all new and existing staff; individuals providing services under a contractual arrangement; and volunteers, consistent with their expected roles for 6 out of 6 employees (RN F, CNA A, LVN H, CNA G, CNA I, and CNA J) reviewed for required training. The facility failed to ensure staff were properly trained in Fall Prevention, HIV, Restraints, Emergency Procedures and Dementia for 6 of 6 employees (RN F, CNA A, LVN H, CNA G, CNA I, and CNA J) reviewed for training at hire and annually. This failure could place residents at risk of receiving care from individuals who did not have the knowledge and skills to properly provide safety from adverse events or other resident life and health complications.

Inspectors wroteBased on interview and record review, the facility failed to ensure all residents had the right to formulate an advance directive for 2 of 16 residents (Residents #27 and #28) reviewed for advanced directives, in that: Residents #27 and #28 was listed as a DNR (Do Not Resuscitate) but had Out-of-Hospital Do Not Resuscitate (OOH-DNR) forms that were incorrectly filled out or had missing required information. These failures could place residents at risk for not having their end of life wishes honored and their records being incomplete/inaccurate.

Inspectors wroteBased on interview and record review, the facility failed to use the services of a Registered Nurse (RN) for at least eight consecutive hours a day, seven days a week for 10 out of 90 days (01/11/25, 01/12/25, 01/25/25, 01/26/25, 02/08/25, 02/09/25, 02/15/25, 02/16/25, 02/22/25, and 02/23/25) reviewed for RN coverage. The facility failed to ensure they had RN coverage 8 hours a day, 7 days a week for the following weekend days: 01/11/25, 01/12/25, 01/25/25, 01/26/25, 02/08/25, 02/09/25, 02/15/25, 02/16/25, 02/22/25, and 02/23/25 This failure could place residents at risk for inconsistency in care and services.

Inspectors wroteBased on observations, interviews and record review, the facility failed to prepare food in a form to meet individual needs in 1 of 1 kitchen reviewed for dietary services in that: The facility failed to ensure puree meat, puree vegetables, and puree pasta were prepared to a smooth uniform texture. This failure could place residents at risk for choking.

Inspectors wroteBased on interview and record review, the facility failed to electronically submit to CMS complete and accurate direct care staffing information, including information for agency and contract staff, based on payroll and other verifiable and auditable data in a uniform format according to specifications established by CMS for 1 of 1 facility reviewed for administration (Fiscal year 2024 for the second quarter January 1, 2024, to March 31, 2024). The facility failed to submit PBJ (Payroll Based Journal) staffing information to CMS for the 2nd quarter of the fiscal year 2024. This failure could place residents at risk for personal needs not being identified and met due to staffing.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that the resident environment remained as free of accident hazards as was possible in 2 of 3 common resident baths (Tan and Mauve Halls) in that: The facility failed to ensure chemicals were not stored with resident toiletries and personal items in 2 of 3 common resident baths (Tan and Mauve Halls). These failures could place residents at risk for accident hazards resulting in injuries.

Inspectors wroteBased on observation, interview, and record review, the facility failed to offer, based on a resident's comprehensive assessment, a therapeutic diet when there was a nutritional problem, and the health care provider ordered a therapeutic diet for 3 of 3 residents (Residents #18, 72 and 73) reviewed for nutrition status. The facility failed to provide Residents #18, 72 and 73 with their physician ordered therapeutic diets that included fortified foods for the noon meals on 7/23/24, 7/24/24 and 7/25/24. This failure could place residents at risk for hunger, weight loss and chemical imbalances.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to maintain an infection control program designed to provide a safe, comfortable, and sanitary environment to help prevent the development and transmission of diseases for 3 of 4 residents (Residents #3) reviewed for infection control. 1. CNA A failed to utilize proper hand hygiene during incontinence care for Resident # 3. 2. CNA C failed to utilize proper hand hygiene during incontinence care for Resident #172 3. The facility failed to implement enhanced barrier precautions for Resident #18. These failures could place residents at risk for infection and cross contamination.

Inspectors wroteBased on interviews and record reviews the facility failed to ensure the residents had the right to participate in, his or her treatment which included the right to be informed in advance, by the physician or other practitioner or professional, of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options and to choose the alternative or option he or she preferred, for 3 of 13 residents (Residents #8, #72, #222) reviewed for resident rights. The facility failed to obtain a signed informed consent based on information of the benefits, risks, and options available for: Residents #8 prior to the administration of Lorazepam and Trazodone; Resident #72 prior to the administration of Trazodone; Resident #222 prior to the administration of Seroquel and Lorazepam. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure PRN orders for psychotropic drugs are limited to 14 days unless the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, for 2 of 16 residents (Resident #3 and Resident #72) reviewed for unnecessary medications. - The facility failed to ensure Resident #3 had a stop date or duration for PRN alprazolam (a medication used to treat anxiety). - The facility failed to ensure Resident #72 had a stop date or duration for PRN Trazadone (a medication use to treat insomnia). These failures could put residents at risk of possible psychotropic medication side effects, adverse consequences, decreased quality of life, and dependence on unnecessary medications.