Memorial Hospital Ltcu (village Manor)

Inspectors wroteThe facility had a census of 65 residents. Based on record review and interview, the facility failed to submit complete and accurate staffing information through the Payroll Based Journal (PBJ) as required. This deficient practice placed the residents at risk for unidentified and ongoing inadequate nurse staffing.

Inspectors wroteThe facility had a census of 65 residents. The sample included 17 residents. Based on observation, record review, and interview, the facility failed to notify the physician of changes in status or condition for Resident (R) 168, who made statements of self-harm. This placed the resident at risk of delayed treatment due to a delay in physician involvement.

Inspectors wroteThe facility had a census of 65 residents. The sample included 17 residents with one reviewed for missing personal property. Based on observation, record review, and interview, the facility staff failed to log and promptly resolve Resident (R) 18's grievance when she reported to staff that she had missing clothing items. This placed the resident at risk for unresolved grievances and decreased quality of life.

Inspectors wroteThe facility had a census of 65 residents. The sample included 17 residents with one reviewed for abuse. Based on observation, record review, and interview, the facility failed to identify an injury of unknown origin as potential abuse and report immediately to the administrator for Resident (R) 57, who had bilateral (both sides) upper arm bruises. This placed the resident at risk for further injury and unidentified abuse or mistreatment.

Inspectors wroteThe facility had a census of 65 residents. The sample included 17 residents with three reviewed for hospitalization. Based on record review and interview the facility failed to provide a written notice for a facility-initiated transfer for Resident (R) 42 or his representatives as soon as practicable when he was transferred to the hospital. The facility also failed to notify the Office of the Long-Term Care Ombudsman (LTCO-a public official who works to resolve resident issues in nursing facilities) of R42's discharge. This placed the resident at risk for impaired rights and uninformed care choices.

Inspectors wroteThe facility had a census of 65 residents. The sample included 17 residents. Based on observation, record review, and interview, the facility failed to provide Resident (R)42 or his representative with written information regarding the facility bed hold policy when R42 was transferred to the hospital. This placed R42 at risk for impaired ability to return and resume residence in the nursing facility.

Inspectors wroteThe facility had a census of 65 residents. The sample included 17 residents. Based on record review and interview the facility failed to complete a recapitulation (summary) post-discharge for Resident (R) 17, who had a self-initiated discharge from the facility. This placed the resident at risk of unidentified and unmet care needs.

Inspectors wroteThe facility had a census of 65 residents. The sample included 17 residents. Based on observation, record review, and interview, the facility failed to provide medically related social services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of one sampled resident, Resident (R) 168, who made statements of self-harm. This placed R168 at risk for further decline in his emotional and mental well-being.

Inspectors wroteThe facility had a census of 65 residents. The sample included 17 residents. Based on observation, record review, and interview, the facility failed to ensure an appropriate indication of use or a documented physician rationale which included the multiple unsuccessful attempts for nonpharmacological symptom management and risk versus benefits for the continued use of an antipsychotic (class of medications used to treat mental disorder characterized by a gross impairment in reality testing) for Resident (R) 43. This placed the resident at risk for unnecessary psychotropic (alters mood or thought) medication and related complications.

Inspectors wroteThe facility had a census of 65 residents. The sample included 17 residents. Based on observation, record review, and interview, the facility failed to store and label biologicals, including insulin (a hormone that lowers the level of glucose in the blood) as required when staff failed to place an open date on Resident (R) 22's Admelog Solostar (fast-acting insulin) and Tresiba (long-acting insulin) insulin pen (a device used to inject insulin). This placed the resident at risk of receiving an expired and ineffective dose of insulin.

Inspectors wroteThe facility had a census of 72 residents. The sample included 18 residents. Based on observation, record review and interview the facility failed to provide adequate assistance for Resident (R) 4 with transfers and failed to ensure a safe environment for four cognitively impaired independently mobile residents who had access to chemicals on a housekeeping cart.

Inspectors wroteThe facility had a census of 72 residents, with three reviewed for Center for Medicare and Medicaid Services (CMS) Beneficiary Liability notices. Based on record review and interview, the facility failed to provide on the CMS form 10055, the estimated cost to continue services for skilled services to the resident or their representative for two of three reviewed residents, Resident (R)45, R47, and R177, placing the residents at risk for uninformed decisions regarding skilled services

Inspectors wroteThe facility had a census of 72 residents. The sample included 18 residents, with five reviewed for unnecessary medications. Based on observation, record review, and interview, the facility failed to develop a comprehensive care plan for Ativan, which required a Black Box Warning for one sampled resident, Resident (R) 47. This placed the resident at risk for adverse side effects.

Inspectors wrote- The Electronic Medical Record (EMR) for R2 documented diagnoses of cerebrovascular accident (stroke), hemiplegia (paralysis of one side of the body), depression (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness and emptiness), and need for assistance with personal cares. R2's Quarterly Minimum Data Set (MDS), dated [DATE], documented R2 had intact cognition and required limited assistance of one staff for bed mobility, transfers, dressing, toileting, and supervision and set-up assistance for personal hygiene. The MDS further documented R2 required extensive assistance of one staff for bathing. The admission MDS, dated 12/19/22, documented R2 had intact cognition and required limited assistance of one staff member for bed mobility, transfers, dressing, ambulation, toileting and personal hygiene. [...]

Inspectors wroteThe facility had a census of 72 residents. The sample included 18 residents, with five reviewed for unnecessary medications. Based on observation, record review, and interview, the facility failed to obtain a stop date for PRN (as needed) Ativan (antianxiety medication) for two sampled residents, Resident (R) 47 and R58. This placed the resident's at risk for receiving unnecessary medications.

Inspectors wroteThe facility had a census of 65 residents. The sample included 16 residents. Based on observation, record review, and interview, the facility failed to ensure the refrigerator was clean in one of four households.