Memorial Manor Nursing Home

Inspectors wroteBased on observation, staff and resident interviews, record review, and review of the facility's policy titled Dignity, the facility failed to ensure residents ate in a dignified manor in that the facility supplied plastic utensils during meal service affecting three of 34 sampled Residents (R) (R3, R21, and R35). The plastic utensils were difficult for some of the residents to grip and carry food to their mouth for residents with certain disease processes.

Inspectors wroteBased on staff interviews, record review, and review of the facility's policy titled Abuse Prohibition Policies and Procedures, the facility failed to report an alleged staff to-resident verbal abuse to the State Agency (SA) within the required time frame for one of one resident reviewed for abuse. Specifically, an allegation of verbal abuse by Licensed Practical Nurse (LPN) 1 to a resident. The deficient practice had the potential for continued episodes of unreported abuse, which posed potential for intimidation or mental anguish for the victimized residents.

Inspectors wroteBased on observation, interview, record review, and review of the facility's policy titled Abuse Prohibition Policies and Procedures, the facility failed to protect residents during an active investigation of alleged staff to resident verbal abuse by Licensed Practical Nurse (LPN) 1, who was permitted to work while the facility's Administrator conducted an active investigation for one of one abuse investigation reviewed. The deficient practice had the potential for continued episodes of staff-to-resident verbal abuse and the potential for victimized residents to suffer from intimidation or mental anguish.

Inspectors wroteBased on observation, interview and record review, the facility failed to assist one out of 34 sampled Residents (R) (R44) with turning and repositioning. The deficient practice has the potential to cause the resident skin breakdown. Findings Include: Review of R44's Electronic Medical Record (EMR) revealed R44 admitted to the facility with diagnoses that include but not limited to of venous insufficiency, diabetes, and peripheral vascular disease. Review of R44's admission Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 4/5/2025 in the EMR under the MDS tab for Section C (Cognitive Patterns) revealed a Brief Interview for Mental Status (BIMS) score of 14 out of 15 which indicated R44 was cognitively intact; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide timely and complete incontinent care for two out of 34 Residents (R) (R44 and R45) reviewed for incontinent care. This failure placed the residents at risk for skin breakdown and/or risk for transmission of infection to the urinary tract.

Inspectors wroteBased on interviews and record review, the facility failed to have a system in place to ensure ongoing assessments of the resident's condition and monitoring for complications before and after dialysis treatments for one of one Resident (R) (R47) receiving dialysis treatments. The failure created the potential for the resident's quality of care to be compromised.

Inspectors wroteBased on observation, interview, and record review, the facility failed to adhere to infection control practices during peri care related to the staff failing to change gloves and perform hand hygiene for three out 34 sampled residents (R44, R45, R308).

Inspectors wroteBased on observations, staff interviews and review of the facility's policy titled, Care of the Resident with a urinary catheter, the facility failed to ensure that four of six residents (R) (R2, R3, R9, R10) with indwelling catheters were secured and stored properly. Specifically, the facility failed to ensure that R2, R3, and R10's catheter tubing was secured with catheter straps, and R9's catheter drainage bag was not stored on the floor.

Inspectors wroteBased on observations, interviews, record reviews, and review of the facility policy titled, Activities of Daily Living (ADLs)/ Maintain Abilities the facility failed to provide ADL Care for three of three Residents (R) (R# 6, R#29, and R#49). Specificall, the facility failed to ensure nail care was provided for R#6 and R#49. The facility also failed to ensure that R#29 received foot care from podiatrist ( Physician that specialises in foot care)on a regular basis.

Inspectors wroteBased on staff interview, family interview, and review of the facility policy titled, Change in Condition Notification, the facility failed to notify the designated resident representative or family member of significant changes for one of five Residents (R) R#22. Specifically, the facility failed to notify the responsible party (R/P) for R#22 of the transfer to the Acute hospital from the dialysis clinic on January 11, 2023.

Inspectors wroteBased on observations, record review, staff interview, and review of the facility policy titled, Nursing Care Plan the facility failed to develop a care plan which addressed the podiatric and diabetic care needs for one Resident (R) #29. The deficient practice had the potential to affect the residents' care regimen by not ensure all care needs were addressed in the person-centered Plan of Care for R#29.

Inspectors wroteBased on observation, staff interview, review of facility documentation, and review of the policies titled, Food Storage and Food Contamination, the facility failed to monitor dishwasher temperature (temp) daily to ensure proper wash and rinse temps were in a safe range; failed to discard expired foods in the dry storage area; failed to ensure opened food items in the walk-in cooler were properly labeled and dated; failed to ensure opened food in the walk-in freezer were securely wrapped, labeled and dated; and failed to maintain sanitary conditions of the two-compartment sink. This had the potential to affect 88 of 95 residents receiving an oral diet.

Inspectors wroteBased on record review and staff interview the facility failed to provide a Notice of Medicare Non-coverage (NOMNC) to two of three residents (R) (#17 and #58) who were reviewed after being discharged from Medicare Part A Services and remained in the facility.

Inspectors wroteBased on staff interview and record review, the facility failed to develop a baseline care plan for three residents (R), (#53, #83, and #142) of 44 sampled residents.

Inspectors wroteBased on observation, record review, and staff interview, the facility failed to ensure the Minimum Data Set (MDS) was coded correctly for one resident (R) (#51) related to the use of restraints and for one resident (R#27) related to receiving dialysis services of 44 sampled residents.

Inspectors wroteBased on observation, record review, and staff interviews the facility failed to follow the care plan related to oxygen therapy for one of 44 residents (R) (#75) reviewed for care plans.

Inspectors wroteBased on observation, interview, and record review it was determined that the facility failed to ensure appropriate services and assistance were provided to maintain or improve mobility when the residents demonstrated a limited mobility for one of 44 sampled residents (R) (#142).

Inspectors wroteBased on observation, record review, staff interviews, and review of the facility policy titled Monitoring Oxygen Therapy the facility failed to follow the Physician's Order for one resident (R) (#75) of 20 residents receiving oxygen.

Inspectors wroteBased on observation, record review and staff interview, the facility failed to administer eye drops in a sanitary manner for one resident (R) (#65) of two residents observed, failed to ensure that one resident room of 56 resident rooms had sanitizer available for staff usage, failed to ensure clean linen was not contaminated in the laundry area, and failed to ensure that one of three shower rooms was maintained in a sanitary manner to prevent the spread of disease.